Next time you get ready to Own the Chest Tube, think about these 2 angiography images of the course of the intercostal arteries.

No Ethel, the intercostals aren’t stuck firmly to the inferior margin of the rib.They wander all over creation. Perhaps, they intentionally wiggle and try to impale themselves on the tip of your needle. I believe that one vessel in the second image crosses the equator into northern Queensland.

Yoneyama H, Arahata M, Temaru R, Ishizaka S, Minami S. Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography. Intern Med. 2010;49(4):289-92. Epub 2010 Feb 15. PMID: 20154433.

Here’s the free fulltext link for you: http://www.jstage.jst.go.jp/article/internalmedicine/49/4/289/_pdf

Thanks to Erik Adler, MD  for finding this truly obscure but thoroughly frightening little article.

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

The ninth edition of our weekly series of eminence-based evidence:

A free weekly resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 8 recommended reads. Find out more about the R&R in the FASTLANE project here and check out the team of contributors from all around the world.

This week’s ‘R&R Hall of Famer

• Batchvarov VN, Malik M, Camm AJ. Incorrect electrode cable connection during electrocardiographic recording. Europace. 2007 Nov;9(11):1081-90. Epub 2007 Oct 10. Review. PMID: 17932025.

This paper is a thing of beauty for the ECG nerd – all the ways incorrect lead placement can play havoc with an ECG.

Recommended by Chris Nickson
Fulltext

This week’s R&R recommendations

Critical Care

• Batchvarov VN, Malik M, Camm AJ. Incorrect electrode cable connection during electrocardiographic recording. Europace. 2007 Nov;9(11):1081-90. Epub 2007 Oct 10. Review. PMID: 17932025.

This paper is a thing of beauty for the ECG nerd – all the ways incorrect lead placement can play havoc with an ECG.

Recommended by Chris Nickson
Fulltext

• Beck LH. Should the actual or the corrected serum sodium be used to calculate the anion gap in diabetic ketoacidosis? Cleve Clin J Med. 2001 Aug;68(8):673-4. PMID: 11510523.

If only I had a dollar for every time someone has asked me the question this little paper succinctly answers…

Recommended by Chris Nickson
Fulltext

International and Tropical Medicine

Pediatrics

Quirky, Weird and Wonderful

Toxicology

Trauma

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of fame You simply MUST READ this!		R&R Hot stuff! Everyone ‘s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R WTF! Weird, transcendent or funtabulous!
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R Mona Lisa Brilliant writing or explanation

That’s it for now…

That should keep you busy for a week at least… Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

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

Welcome to the splendid 55th edition!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.

The Most Fair Dinkum Ripper Beaut of the Week

SMART EM

• The uber geek’s of emergency medicine are back with a lengthy look at Stress Testing: A Moment of Clarity - the SMARTEM team dives down through 40,000 leagues of medical literature on the utility of using the exercise stress testing in the emergency department. Congratulations David and Ashley on taking out top spot!

The Usual Suspects

Academic Life in Emergency Medicine

• Trick of the Trade: Minimizing propofol injection pain - great tips inspired by Andy Neill’s recent contribution to R&R In The FASTLANE.
• Paucis Verbis: Pediatric fever without a source (Birth-28 days) - A nice approach guaranteed to come in handy!

Free Emergency Medicine Talks

• Joe’s pick of the week is by Karl Nibbelink on the difficult topic of I Suspect My Colleague Is Using Drugs: What should I do?

The Poison Review

• “Legal Highs”: new psychoactive drugs - not the greatest article on new psychoactive drugs – but provides some useful facts.
• Honey Don’t: grayanotoxins, sex, and affairs of the heart - this honey is most probably not something to spread on your toast. This is an amazing pair of cases.
• Bath salts and necrotizing fasciitis: a case report -  you have been warned!

Dr Smith’s ECG Blog

• Left ventricular Aneurysm Morphology Distorted by Right Bundle Branch Block – Mimicking Acute STEMI with RBBB.
• Chest pain and hypotension in a patient who is 3 weeks post STEMI - is the patient having ongoing ischaemia or a complication post-STEMI?

Emergency Physicians Monthly.

• 11 Benchmarks That Should Matter to EPs. Take home point: Benchmarks serve no purpose if they do not reflect the needs and perceptions of all the stakeholders.
• Sickle Cell: 10 Things Every EP Should Know about SCD.

Impactednurse

• You are twice as likely to die when flying on this aircraft – You wouldn’t fly on this plane with that risk- but patients that attend the emergency department are exposed to the same risk.
• 53 secrets the ED staff won’t tell you – What there is only 53??
• Ian gives a tribute in praise of our wardsmen (and women).

The Rest Of The Best

CLIC-EM

• Some excellent little pearls and pitfalls on a common ED resus medication - Know Before You Push — Adenosine - remember help your electrophysiologist out get a good ECG before giving.

Intensive Care Network

• Craig Hore shares with us an interesting case in Emergency Pacing - and shares with us some excellent pitfalls in for transcutaneous pacing.

Emergency Medicine Literature of Note

• Further Harms of IV Contrast - Just in case you needed another reason to not order a contrast CT.
• The Harmful Rush To Hypothermia - Hard to know what to actually do with data.  Is early hypothermia truly harmful?

Broome Docs

• Consult Skills 2: When Agendas Collide or “Physician Know Thyself” – Casey shares his approach to the difficult patient or the difficult conversation.

UMEM Educational Pearls

Michael  Winters pearl of the week - SAH and Pulmonary Edema – Think Twice About Diuresis!

• Delayed cerebral ischemia (DCI) is the most common cause of secondary neurologic injury in patients with aneurysmal subarachnoid hemorrhage (SAH).
• Intravascular volume depletion is one of several factors thought to cause, or worsen, DCI.
• Pulmonary edema frequently occurs in patients with SAH.
• A recent study in patients with SAH and pulmonary edema demonstrated that many were not volume overloaded.  In fact, many were intravascularlyvolume depleted.
• Think twice about aggressive diuresis in patients with SAH and pulmonary edema, as this may exacerbate volume depletion and may worsen DCI.

Emergency in the Shed

• David smashes out another brilliant podcast episode when he teams up with anaesthetic consultant Simon Pattullo to provides us with an approach to the ‘Can’t Intubate – Can’t Ventilate” scenario – check out Airway-Preparing to Fail.

Emergency Medicine Ireland

• Revitalising Professionalism - “The fact that medicine rarely cures many of the diseases that we attend to makes it even more morally significant.”
• Anatomy for Emergency Medicine – #5 CSF Circulation

Anatomy for Emergency Medicine – #5 CSF Circulation from Andy Neill on Vimeo.

EmergSource.com

• Learning to learn - The secret to life long learning is simple. Everyday, and every patient ask yourself ‘Could I have done that better?’

ED Trauma and Critical Care

• Amit shares with us some of his revision notes on Radiation Illness and High Altitude Illness.
• Management of The Mangled Extremity - a new algorithm approach from some recently published literature.
• As Australian’s continue to have a love affair with Bali – ED doc’s and nurses need a good understanding on Saturday Night Dengue Fever & Staying Alive - Worth reading!
• Bleeding Hell! Dabigatran is Here. Forget the Vit K or prothrombinex its straight of to dialysis for these patients!

Pediatric Emergency Medicine Morsels

• This weeks morsel is on how to rotate back the Malrotation.

EMdose

• Vasopressors in Neurogenic Shock - Remember: shock in a trauma patient should be presumed to be secondary to hemorrhage until proven otherwise.  If you’re certain it’s neurogenic shock, then optimize BP with crystalloid fluids, followed by a pressor as above to increase your MAPs and increase spinal perfusion.
• Hypothermia in Trauma - Until further word, preventing and correcting hypothermia is recommended.

The Trauma Professional’s Blog

• The Societal Cost of ED Thoracotomy - Bottom line:  use the guidelines and save your own health, safety and hospital resources. Is it really worth it if you know the patient will not survive?
• Can Lead Poisoning Occur After A Gunshot? -  Not something you come across every day, but some important pearls and pitfalls here on treatment options.
• A Cool Way To Remove Embedded Foreign Bodies - This is a very slick technique that promises to dramatically increase the success rate and decrease complications from removing foreign bodies.

A Life at Risk: the Emergency Physician

• Septic Arthritis and Arthrocentesis - Although arthrocentesis is not a risk-free procedure, synovial fluid analysis is essential for the diagnosis.

More Musings (of a Distractible Kind)

• Good Things in Medicine #2: Puzzles – Problem solving is central to being a good diagnostician. The quirky and insightful Rob Lambert tells us why diagnosis is cool, and how to get good at it.

 Twee-D and Twitcal Care

A holistic orthopaedic surgeon is one who cares for the whole bone and not just the fracture.

January 24, 2012 2:58 pm via Twitter for iPhoneReplyRetweetFavorite

@otorhinolarydoc

Trainee ENT Surgeon

News from the Fastlane

• Yosef Liebman’s Emergency Medicine Update January 2012 - is out…so check it out!
• There is still time to go into the draw to win in the Test The Textbook Trilogy.

The Final Words

• ‘Accept ignorance, accept that you just don’t know, once you get that into your head you’ll start to learn.’

 - Jim Ducharme

• “One of the major biases in risky decision making is optimism. Optimism is a source of high-risk thinking.”

- Daniel Kahneman

That’s it for now…

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter:  kane AT lifeinthefastlane.com

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

This is the third edition of EMU to be modified for LITFL readers. You can download the original pdf version here, which also contains essays on UTIs, pain and acute porphyria. Check out previous editions of EMU on LITFL here.

If you’d like to subscribe to EMU directly send an email to: jbleibmd AT yahoo.com 

Learn about the latest emergency literature by clicking on the show/ hide links below:

Who should you let the intern see?

Children banged on the head and return to sports

Subsegmental PE… so what?

Paracetamol may increase risk of childhood asthma

Prehospital transcranial doppler to guide therapy in traumatic brain injury

Quick ways to BLS are just as good for med students

Statins for septic shock? For pretreatment in PTCA?

Radiation exposure of kids suffering from blunt trauma

Spinal manipulation for radiculopathy?

Emergency physicians dealing with death

Keeping up with ED Ultrasound

Problem with the scrotum? Cut it open!

Be careful with cough mixtures in transplant patients

AF: procainamide drip then shock

Unruptured cerebral aneurysm - what to do?

AF guidelines compared; positive troponin in SVT - so what?

Should healthcare workers be screened for MRSA?

Do oximes work for organophosphate poisoning?

Say no to resonium/ kayexylate in hyperkalemia?

Toxicity of synthetic cannabinoids

NSAIDs no good for the heart - including naproxen

How to stop propofol from stinging; comments on ketamine

Arm straightening in elbow injuries; bowel sounds in obstruction- useful or not?

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

What do you get when you combine salted pork, a full moon, William the Conqueror, Stendhal and a swollen labia majora?

The 74th edition of the FFFF of course!

Question 1

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

From Humphreys et al (2011)

Reveal the funtabulous answer!

Question 2

Is a full moon associated with increased behavioural disturbance in emergency departments?

Reveal the funtabulous answer!

Question 3

What is the key component of the ‘William the Conqueror’ diet?

Reveal the funtabulous answer!

Question 4

What is Stendhal syndrome?

Reveal the funtabulous answer!

Question 5

A competitive athlete asks for your advice about an embarrassing medical problem she has developed… a unilaterally swollen labia majora. What sport does she most likely compete in?

Reveal the funtabulous answer!

Want An Easy Way To Score Higher On The FFFF?

It’s easy — write the questions yourself!
You can submit a question to the FFFF using this form.

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

The eighth edition of our weekly series of eminence-based evidence:

A free weekly resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 14 recommended reads. Find out more about the R&R in the FASTLANE project here and check out the team of contributors from all around the world.

This week’s ‘R&R Hall of Famers’

• Abd-el-Maeboud KH, el-Naggar T, el-Hawi EM, Mahmoud SA, Abd-el-Hay S. Rectal suppository: commonsense and mode of insertion. Lancet. 1991 Sep 28;338(8770):798-800. PMID: 1681170

Recommended by Rob Orman
Learn more: ERCAST – The Suppository Conundrum

• Hudson ML, Moore GP. Defenses to Malpractice: What Every Emergency Physician Should Know. J Emerg Med 2011;41:598-606. PMID: 21094012

Recommended by Leon Gussow

This week’s R&R recommendations

Airway

Critical care

Emergency medicine

Pediatrics

Quirky, weird and wonderful

Retrieval, prehospital and disaster

Toxicology

Trauma

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of fame You simply MUST READ this!		R&R Hot stuff! Everyone ‘s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R WTF! Weird, transcendent or funtabulous!
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R Mona Lisa Brilliant writing or explanation

That’s it for now…

That should keep you busy for a week at least… Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

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

aka American ER Doc Gone Walkabout… 009

Arriving in Tassie, I had only the vaguest sense of how the intern-resident-registrar system compared to our US system. (OK, so planning ahead has never been my strong point. Works out amazingly well. Sometimes.)

By the time I finished, I had concluded:

The system doesn’t make much difference, we all figure it out and do pretty much the same things by the time we’re done training. Interns are interns, and they all look and function pretty similarly. The residents in Oz have a much greater knowledge base than interns, but not being into the ER track, don’t have quite the mindset of ER Docs – they’re doing inpatient workups – just a little closer to the front door. The registrars in their first few years are comparable to our PGY 2 and 3 residents, and during their later years are more comparable to our fellows and junior faculty – really functioning very independently and occasionally discussing particularly challenging cases with the consultants – as two faculty members would interact on a tough case.

On to some details. In the US resident physicians are doing their specialty training. In Australia, residents are doing general training – the Americans might think of it as an extended rotating internship, while the registrar has moved on from residency to specialty training.

For you Aussies: the US system is a post-graduate medical school system: high school, then (usually) 4 years of college, 4 years of medical school, and then for ER Docs, straight into specialty training – called residency in the US. 3 or 4 years of specialty residency training right out of medical school. Many, especially if interested in academics, do another 1 or 2 years of fellowship training in a subspecialty – wilderness medicine (I think that means that you go skiing or bushwalking on your days off), ultrasound, education, etc.

During that first year of residency, you’re called an intern even though you’re already in the training program, and spend part of the year in the ER, and part of the year rotating through a variety of inpatient services. From there on out it’s all ER, all the time – a few electives thrown in.

Remember, Aussies, the Americans residents are in the EM training program and there is no such thing as a registrar in the US system (except the guy that does the paperwork at the front desk). And I’ll use the terms “attending” and “consultant” interchangeably for the fully trained, independently working, board-certified guys.

For the Yanks: some Australian medical schools are directly after high school, (though some are similar to ours with undergraduate college first) – therefore, the interns may seem pretty young. But, here’s where it gets really interesting: rotating internships for everybody, 1 year. Then, “residency” – which is still not a specialty track, and during which you continue to rotate through a variety of specialties. During your residency, you choose and apply for specialty training. Your residency can last for a few years, or for lots of years: 3-5 seems common.

(I won’t mention the brutality and lack of pertinence, except for a small number going into bench research, of the primary exams.)

Then, on to specialty training – as a registrar. Here’s where the registrars begin to function as what the Yanks consider residents. But, a few differences: the Reg already has spent time in the ER as part of his rotations during internship and residency. The Reg has several years of broad background in clinical medicine, surgery, peds, OB/Gyn that our residents don’t have. The Reg has also had several years of exposure to a variety of clinical services to assist him in making his choice for specialty training, rather than the intense pressure in the US to make your choice during 3rd year of medical school so that you can do sub-internships in that specialty during your 4th year and have your residency applications done half-way through your 4th year.

The years as registrar are a bit different from the US residency:

More years. Usually 4-5. Less defined curriculum – after the minumum required of 4 years of ‘advanced training’, you remain a registrar as long as you need until you can pass the specialty exam (Australasian College of Emergency Medicine – ACEM) – it would take me approximately 12 years, I think, to get smart enough. You don’t enter a single registrar program and stay there – you go through a variety of independent positions that are typically 6 or 12 months long. Some time on other services, like Critical Care. Some time at rural hospitals. Maybe even some time as a Retrieval Registrar – flights to bring patients from outlying hospitals in to the larger centers. Take the ACEM exam when you feel ready, and keep on with training until …….well, until you can pass the exams. And the pass rate for the ACEM is lower than for the ABEM exams – about 50-60%, if I hear correctly. Why so low? Take a look at the LITFL exam resources and try some of the ACEM questions. You’ll understand. They are insanely difficult – no way that I could pass the ACEM exam. ABEM looks simple.

That program has a great advantage: not everyone can grasp the required knowledge, nor acquire the required skills at the same pace. In the US, you’ve got 3 or 4 years depending on the program. Learn it or fail. Or fail to learn it, and get eased through. In the less defined Aussie system, take 3-4-5 (?more) years and get it done at a pace appropriate to your skills and speed of learning.

Editor’s note: There are limitations in the Australasian system on the number of times the exam can be sit, and the time taken to pass the exam — but there is a lot of flexibility.

As a Registrar, you’re pretty independent – you see patients, supervise the interns and residents as in the US, but unlike the US, often present a case to a consultant/attending only if you wish to. Particularly with the senior registrars, we would often go through several shifts without discussing a patient. Not at all sure that I liked that, how else do we learn except by sharing & discussing – even when we already know the answer. Sometimes I felt that I was asking for opinions on my patients, more than the reverse. (And there were some skills that I had long ago abandoned to our nurses and paramedics, but had to request help from the registrars – or relearn the skills for 3 months. I chose the easier route.)

The junior registrars in their first and second training year, are clearly further along than our PGY 1 and 2 – no surprise, since they’ve had 3-5 years of general clinical experience. And, by the time they’ve been registrars for a few years, they function more as we would expect of a fellow or junior faculty. Even though the junior registrars are less seasoned in emergency medicine – especially some of the procedural stuff – they commonly knew more than I did about medicine outside of emergency medicine. That broad background does indeed show up, and is useful. The knowledge required for the primary exams, however, did not ever rear its ugly head.

But, in the end, if you blindfolded me, and disguised the accents, I’d have a hard time sorting out the differences in capabilities between the trainees in Tassie, and those at home.

But, you may ask, wouldn’t 8-10 years of training, even if the hours worked are less crushing, constitute a severe personal and financial load? Well, a little context:

The Australians have contracts that call for 37 hours a week, plus 5 hours of educational sessions whereas the US it’s typically 48 hours of clinical time plus educational time – and in the realm of electronic medical records and the pressure to “move the meat”, at least at my hospital, many of the house staff are spending hours after each shift finishing up their charting. Never happened at LGH – done and gone as soon as handover rounds were done. So, the weekly work load in the US is about 25% – at least – greater than in Australia.

Americans finish medical school with a debt load perhaps 4-5 times that of Aussies finishing med school (perhaps a bit higher debt load for those finishing a graduate, rather than undergraduate medical school). An Australian intern earns 30-50% more per year – plus 5 weeks of paid vacation, plus state holidays, and some of that income can be tax-free – than American interns. And, as the Australian moves through the system, the year-to-year increase in salary is substantially greater than in the US. So, as a registrar, the Australian physician has a much more reasonable debt load, work hours compatible with a career – rather than a right of passage, and earns a comfortable living. He appears to be passing through stages of a career. Whereas the American resident is passing through an unsustainable, though prolonged and brutal right of passage – at the end of which he has a sudden transition, seemingly overnight from an underpaid, overworked trainee to a fully formed, newly omniscient, and generously compensated attending. I exaggerate, but only a little.

Think about it: if you’re an engineer or businessman, you don’t finish training, then join a firm or start your own business and become the senior partner. You gradually work your way up as you gain experience and establish the tentacles of power. But US medicine assumes that as soon as you have that certificate, you’re ready for full do-it-all medicine. Perhaps a slower and lower-angled ramp up to full certification has some advantages.

Another observation about the residents and registrars with whom I worked: diversity. In the US, we consider diversity in skin color. But, not much in backgrounds. The Australian registrars were from the big island, the little island, India, Africa, Burma, and Singapore. What’s up, can’t Oz grow their own? Consider this: in the US, about 11% of our population was born abroad. In Australia, that number is over 30%. With that kind of a rate of growth through immigration, it’s not surprising that immigrant doctors need to be part of the equation. The diversity of background was sometimes challenging – not all of our residents and registrars were starting from the same knowledge and experience base, and often enriching – both culturally and medically (“Oh, yeah, boss, we saw lots of typhoid in India – here’s how we did it……”).

If I was doing training now, I think I might like the longer but less brutal program that really felt to me, as an observer, much more as a progression through current career stages, rather than the US training that seemed more an independent step to a future career.

Don’t forget to read previous installments of ‘American ER Doc Gone Walkabout‘.

References

• Salaries in the US (pdf)
• Salaries in Australia

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

aka Postcards from the Edge 004

This ‘postcard from the edge’ is by Swedish Emergency doctor Katrin Hruska (@akutdoktorn), who writes a predominantly Swedish language blog called akutdoktorn.

I am a born optimist, which is why I have taken on the struggle to establish emergency medicine as a specialty in Sweden. Since EM is a supraspecialty I had to take the long way through an internal medicine residency, but now I am at least seeing the end of my EM training. I am also mildly adventurous. Not in the crazy, head-first, emergency physician way, but in a safe, Swedish way. Somehow I managed to convince my program director that a rotation abroad would make a great contribution to my education, so me and my family moved to Botswana in southern Africa for four months.

I came to Botswana for an ED rotation, hoping to do some good and learn something from it. Four months later I am ready to leave and I look back at my experience with a sense of relief. At least I didn’t kill anybody. I think.

Primum non nocere. First, do no harm. A principle that, hopefully, is more sacred to us doctors than the traditional medicine men here, whose remedies worsen the metabolic acidosis of babies with diarrhea and cause hematuria and acute renal failure in adults. Of course we know better than those quacks. We are highly educated medical doctors who practice evidenced-based medicine. Right?

Only I have learned evidenced-based in a kind of EM rule-in/rule out or good/bad way. Intubation for traumatic brain injury with GCS less than 8 is good. Intubation without proper skills and equipment is bad. But what do you do when that is all you have to work with? What is the threshold for intubation if your only airway adjunct is an ET tube size 7,5 or 9 and there is no endtidal CO2? And you are out of oral airways, except the infant sized? And there is only one ventilator, which does not work with assist-control settings, so you have to sedate the patient. And getting blood gases is a hassle since you have to rely on the benevolence of the ICU staff to analyze them? And you are lucky to even get the help of inexperienced A&E nurses?

I have no idea if intubating these patients saves more brain than it kills. And four months of experience in this setting has not made it any clearer to me. It has just made me care less. Because even if I try me very best to minimize the risks and optimize the care for a patient, I will later find them alone in the resuscitate room, with no one there to hear the alarms, while waiting for paperwork to be filled out, transport to arrive or just other doctors to make up their minds. That is when I start to blame the system. And when the system is at fault, you sort of resign from responsibility. Irresponsible doctors are lousy caregivers, so I struggle to feel responsible for every single one of my patients. I never thought it would be so hard and I doubt that I could do it for much longer.

I must admit that I had a somewhat naive perception of doctors in resource limited settings before coming to Botswana. I had heard stories about great clinicians who made accurate diagnoses based on clinical findings, auscultating and percussing the patients all over. But the only ones I see assessing chest expansion and vocal fremitus are the medical students. The medical officers have all trained abroad in hospitals with better resources, where you just order a chest x-ray. They are well trained with the same theoretical education as myself. When it comes to experience they are in some ways way ahead of me. After a year of internship they are supposed to work independently and with the patient clientele here, they quickly learn procedures and gain experience of treating very sick patients. They learn and seem to accept that they have to work with what they have got. And since x-rays are readily avalable, they are ordered in the same just-in-case fashion as back home. It is as if whatever resources are available are not limited. Another example of this is the iv fluids. During my stay we were sometimes out of normal saline and sometimes out of Ringers lactate and a few times we were out of both. You can be an expert on fluid resuscitation, but if their are no other fluids available than Dextrose when you are treating a severely dehydrated, septic child you are just as helpless as everybody else. It is an awful experience.

But when the next load of fluids arrives everything is back to normal. Almost anyone who hits the door gets an infusion. If it is there, it will be used until it runs out. In fact the iv fluids are used to clean wounds, since it is the only sterile solution available. If fluids were truly a limited resource and you knew that you only got a certain supply per month, it would not be hard to rationalize their use. The problem is not that fluids and other basic supplies are unaffordable, but that the stocks are not replenished on a regular basis and that running out of fluids, gloves or other necessities is somehow acceptable and seen as something uncontrollable. The most limited resource is structure.

CT scans, on the other hand, are indeed limited. The CT scanner in the hospital cannot do contrast enhanced exams, which means that abdominal and thoracic scans have to be ordered from outside. It is still financed by the government but the costs are much higher and the use is restricted, which means that those scans are hardly ever ordered from the emergency department. We mainly use the CT for brain scans. By some order, the cervical spine cannot be included in such a scan, even if there is a clear clinical indication and the result might actually influence the outcome. At the same time, surgery can demand a CT brain for a patient slightly confused patient with GCS 15 who needs admission for observation after a road traffic accident and refuse to admit without it. We see 85 year olds with hemiparesis, who are transferred from other hospitals for CT scans, only to confirm their strokes. This practice seems reasonable in the rich world, but if resources are limited, is this really where you want to spend your money?

To prioritize is ethically challenging and I don’t think that I, as a visiting doctor and a foreigner in this cultural context, is the right person to tell the local doctors how to use their resources, just because I have been trained to know what is possible in my own setting. And by bringing our way of practicing here, we are indeed prioritizing emergency care over other aspects of health care. If we are guided by patient-oriented outcomes, such as mortality and morbidity, we are probably doing good. But if we use surrogate markers, such as adherence to what is regarded as evidenced-based principles in the rich world, we are diverting resources away from other areas, without knowing with reasonable certainty that we are saving lives. If we successfully resuscitate a patient in cardiac arrest, that patient will need one of the very scarce ICU beds. The return of spontaneous circulation might seem like a victory, but considering how few people actually leave the hospital neurologically intact even with high quality intensive care, we have to ask ourselves if we don’t have more to gain from preventing cardiac arrest than treating it once it has occurred.

The unique dimension of Emergency medicine is time. Sometimes seconds matter and sometimes even days don’t count. Our job is to see the difference. But it is also to plan ahead and lead a team. When you are working in a well organized ED, you don’t realize how much work is done by others than yourself. You just expect carts and trays to be complete and the medicine cabinet to contain the same things today that you used yesterday. You certainly don’t expect the bag-valve mask to be assembled in a way that can give your younger patients bilateral pneumothoraces. Knowing how to work all the equipment yourself is important everywhere, but here it is indispensable.

In some ways emergency medicine here is similar to what I learned as a medical student in the mid-nineties. A myocardial infarction is chest pain with ECG-changes and STEMIs are treated with streptokinase, unless there is a contraindication. A few patients can be admitted or referred to cardiology, but that is more an exception than a rule. What happens with all the MIs that are missed this way? I have no idea. I do know, however, that the step to the current practice, where every tiny increase in troponins is an NSTEMI, is huge. Should the development here follow the same path or is it acceptable to keep missing those MIs, because other areas are more important to improve on first? What about pulmonary embolism? If we did get a CT scanner that could scan for PE, who should we scan? And what would we do with the results? There is not great evidence for anticoagulation to begin with. Who do you start on warfarin if INR monitoring is only done at the main hospital, if you cannot get even plasma to reverse the effect and to get packed red cells for a transfusion can take four hours. If more patients bleed to death, than are saved from dying of PE, we are no better than the traditional medicine men, harming people with toxic remedies.

I am convinced that a well functioning emergency department saves lives. But I think that development has to focus on getting the basics right and minimizing the adverse effects of our interventions. To secure impeccable hygiene and barrier care limits the spread of nosocomial infections at a low cost. To organize the ED in a way that allows good monitoring and an overview of all patients makes it possible to intervene before the patient deteriorates. Excellent on the floor management that stresses team work and communication reduces the unnecessary errors and speeds up processes. Documentation that makes it possible to measure quality and follow-up can help us identify problem areas. It also tells us how our patient population compares to study populations and if the evidence that is available is at all applicable in our setting. Because to use even excellent evidence from a completely different setting is not to practice evidenced-based medicine. If there is no evidence you just have to rely on your clinical judgement and common sense. And keep doing your absolute best for every single patient. In a dysfunctional organization that feels like banging your head against the wall, again and again.

But what else can you do?

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

Welcome to the mind-boggling  54th edition!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.

The Most Fair Dinkum Ripper Beaut of the Week

EM Basic

Top spot this week is taken out by someone new on the podcasting/blogging scene… Steve Carroll over at the simple yet extremely informative podcast EM Basic. This podcast covers all the pertinent topics in EM in a simplified, easy to follow format. To take out top spot this week Steve provied a nuts and bolts simplified approach to the patient presenting with syncope. He covers what tests need doing, all the way through to who needs to stay for further work-up and who can be discharged. Also check out the bonus section on rehydrating the dehydrate patient in the ED.

The Usual Suspects

RESUS.ME

• β-2 agonists could worsen ARDS outcome - the search continues for what actually works and provides benefits in ARDS.
• Caution with intraosseous adenosine. Interesting case series – but was the dose and IO position correct?
• Adjacent haemofiltration catheters can remove CVC drugs - An important consideration when siting your lines in your critical care patients who require renal replacement therapy.
• FIRST: Fluids in Resuscitation of Severe Trauma. Cliffs take on this study: “I’m sure the FIRST trial is going to be quoted for some time to come, including, I suspect, by the manufacturers of certain colloids”.

Emergency Medicine News

• Leon Gussow highlights The Best Toxicology Articles of 2011 and finishes by taking a swipe at the black box warnings.
• Hernia with Acute Pain and Swelling - time to reduced the irreducible.

Academic Life in Emergency Medicine

• Paucis Verbis: this week gives us the heads up on what and when to give Antibiotics for open fractures.
• Trick of the Trade: A handy approach to managing the often challenging Dental Avulsion/Subluxation.

Free Emergency Medicine Talks

• Larry Raney gets Joe’s pick of the week with a presentation on Should We Be Using More Agonist / Antagonist Pain Medicines in the ER?

ER CAST

• Rob is back with another awesome podcast this time teaming up with Ryan Radecki the literature guru from Emergency Medicine Literature of Note to tackle and discuss the ins and outs on Decision Tools: PERC, NEXUS and CURB-65 - they also get some commentary from Scott Weingart from EMCrit, and give LITFL editor Chris Nickson numerous shout-outs.

The Poison Review

• Prehospital naloxone given by nebulized inhaler - time to start considering that nebulized naloxone is safe and effective treatment in patients with suspected opiate overdose and spontaneous respiration.
• Caffeinated energy drinks: do they cause significant acute toxicity? – Are these drinks causing a problem? Leon isn’t convinced what about you?
• Carnitine and valproic acid overdose - is it a reasonable approach? The jury is still out – but Leon thinks so.

Dr Smith’s ECG Blog

• Subtle Anterior Transient Injury Pattern, Not Appreciated -Looks like the LAD occlusion spontaneously reperfused.

Emergency Physicians Monthly.

• Greg Henry promotes a new must read book for emergency doctors and nurses in It is OK to Die. - anybody out there read this book yet? Do you share the same sentiments as Dr Henry? Let us know. 
• Rick Bukata shares with us some new literature focusing on With Discharge Instructions, Less is More - worth a read!

The Rest Of The Best

Intensive Care Network

• Oli is back with another great case-based podcast in An interesting case. Can you try to work out what your differential would be and how you would investigate and manage this case.

PEM + ED

• This months podcast is on Clearing The Pediatric C-spine - remember “Your pediatric patient doesn’t need a decision instrument as much as they need a good doctor.”

Emergency Medicine Literature of Note

• Lies, Damned Lies, and Tamiflu (oseltamivir) -  it doesn’t decrease hospitalisations and only reduces symptoms by about 21 hours – is it worth it??
• 100,000 Incorrect TIA Diagnoses Every Year – a very disappointing study that made its way into the Annals – how??
• Observation For Anticoagulated Head Trauma - will the absence of evidence change our practice in this patient group – be interested to see what others think of this paper

Broome Docs

• Casey introduces us to the art Consultation Skills: Intro and highlights the two different approach he takes towards his consultations – looking forward to reading other post in this series.
• Consult Skills 1: The “normal” strategy: Understand the patient’s point-of-view and prosper. Biggest take home point – “every patient has a story to tell, let them tell it.”
• Irukandji syndrome – the swarm hits Broome-  a nice review on one of the LITFL team’s favourite topics.

UMEM Educational Pearls

Amal Mattu is back again with more brilliant cardiology pearls. This week looks at  coronary risk factors and AMI mortality.

• We’ve noted studies in recent years indicating that cardiac risk factors are ineffective at predicting the likelihood of ACS in patients with acute chest pain (in other words, it’s all about the HPI and EKG!).
• Now there’s evidence also that cardiac risk factors are ineffective at predicting in-hospital mortality in patients that rule in for acute MI. [1]  In fact, this study actually demonstrated that in-hospital mortality is inversely related to the number of cardiac risk factors!
• The bottom line is simple: cardiac risk factors are useful at predicting long-term risk for development of coronary artery disease, but they are NOT useful at in the acute setting.
• Canto JG, Kiefe CI, Rogers WJ, et al. Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction. JAMA2011;306:2120-2127

Emergency Medicine Ireland

• NAC for alcoholic hepatitis - the research is looking promising for this intervention – nice find Andy.

EmergSource.com

• Your Next Patient: A 62 Year Old Man With Advanced Lung Cancer- Brilliant case,  something different for a change, a look towards palliative care in the ED. Palliative care seems on face as far out of the realm of emergency medicine as can be – what do you think?

ED Trauma and Critical Care

• Posterior Sterno-clavicular Dislocation - check out the key points on identifying and managing this rare and diagnostically challenging presentation.
• Dysbarism Made Easy…. A nice revision list of the key terms and points surrounding this topic.

Pediatric Emergency Medicine Morsels

• This weeks Morsel is huge with a review on Pediatric Obesity – just when you thought your job was difficult enough.

EMdose

• Steroids in Acute Spinal Cord Injury - its not the standard of care – and does the evidence even make it a treatment option?
• A nice review and some suggestion on why you attempt to clear patients of the Long Spine Boards asap.
• Catheter Size and Fluid Resus -A review on why short and fat is a good attribute for intravenous catheters and some other things about flow.
• Needle thoracostomy - looks like its time for a new approach.
• Heart rate in hemorrhage - what is the magic heart rate number?

EMpills-pills of Emergency Medicine

• Anterior nasal tamponade anchored - a new approach to packing that bleeding nose.

The Trauma Professional’s Blog

• Pet Peeve: “High Index of Suspicion” - interesting, food for thought!!!
• Does Initial Hematocrit Predict Shock? - Bottom line: Starling was right! Fluid shifts occur rapidly, and initial hematocrit or hemoglobin may very well reflect the volume status of patients who are bleeding rapidly. If the blood counts you obtain in the resuscitation room come back low, believe it! You must presume your patient is bleeding to death until proven otherwise- a must read post!!!

A Life at Risk: the Emergency Physician

• Septic Arthritis in patient with HIV- what is the LR give you on the test you order.

 Twee-D and Twitcal Care

Anaesthetic's ABCDE. Arrive, blame, criticize, depart, everyone else's problem. #joking #iloveanaesthetistsreally

January 21, 2012 6:09 pm via Twitter for iPhoneReplyRetweetFavorite

@4hrEmergencyDoc

ED Doc

News from the Fastlane

• R&R In The FASTLANE 007 is back from its festive break – find out what the experts in EM have been reading lately.
• Want to win one of 3 awesome textbooks? Find out how in Test The Textbook Trilogy!!

The Final Words

• “Seriousness is the only refuge of the shallow.”

- Oscar Wilde

• “There can be as much value in the blink of an eye as in months of rational analysis.”

-Malcolm Gladwell

That’s it for now…

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter:  kane AT lifeinthefastlane.com

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

Shot on board with the paramedics of Pretoria and Johannesburg, TELL ME AND I WILL FORGET illuminates the new social challenges in South Africa, 15 years after the end of its oppressive Apartheid era.

Below is the first 2 minutes of this amazing hour long documentary. I urge you to make the time to watch and digest the rest of the film – it will be an hour well spent

Desperate human circumstance and a wave of violent crime have put immense pressure on the medical system, which is now as divided as the country’s dual economy. With the on going US medical debate, the documentary provides a timely look into the much less glamorous side of the nation that hosted the 2010 World Cup Football Games.

References

• Snag Films (Website, Twitter and Facebook)
• Tell Me and I will Forget – Full Film
• GF Jooste hospital experience

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