“Oh no,  not another goddam series of posts to follow on LITFL!”, you cry.

Relax would ya.

This is the first of an occasional series of posts where I’ll pull together a bunch of book recommendations from our beloved R&R crew. It seems that this posse of medical uber geeks likes to read stuff other than journal articles. I’ve asked them all which books they’d recommend emergency medicine and critical care should or must read — for whatever reason. I’ll be grouping them into loosely woven themes, but the recommendations can be anything — fiction, non-fiction, classic literature, self-help, poetry, comics, pop-up books… you name it.

The theme for the first edition of Books in the FASTLANE is:

‘Reading for kicks and giggles, sometimes amidst despair and darkness’

Here are the 5 recommendations:

Shit my Dad Says by Justin Halpern

“About a guy who moves back in with his father. Book is basically quotes from the dad, and they are funny as hell. His dad is a physician, I think, but this book isn’t medical. Just good old fashion family fun.”
— Rob Rogers

I read this book based on Rob’s recommendation and my zygomaticus majors were aching afterwards from the work out. Interestingly, my own father didn’t seem to think there was anything odd about the fatherly advice given in this book…

Catch 22 by Joseph Heller

“Outrageously funny – the original LOL. Despair and darkness.”
— Gerard Fennessy

“The book that was read, just at that epiphanal moment of angst-ridden teen-hood, which demonstrated that the world of adult-hood upon which one was just about to embark, was no better grounded in sense, than that of the one just about to be left. I will be forever grateful for the reminder that life is based upon the ridiculous, and the mostly meaningless. The medical references were also close to perfect.”
— Michelle Johnston

This is also one of my own all time favourites. From my own short stint in the NZ Army, I can assure this book is more realistic than it seems. Furthermore, the practice of emergency medicine and war seem to have a lot of features in common.

I hate myself and want to die. The 52 most depressing songs you’ve ever heard by Tom Reynolds.

“Had a bad day? plug in your ipad and read this. Funny, witty and not depressing at all!”
— Heike Geduld

I’ve added this to my reading list!

House of God by Samuel Shem

“This is the one book every medical student and intern in my generation seemed to have devoured. Scabrous and still wildly funny, it reads like an episode of “Marcus Welby” directed by Antonin Artaud. As John Updike pointed out in an introduction to the 1993 reprint, the novel “did for medical training what ‘Catch-22′ did for military life”. Absolutely indispensable, even 30 years later.”
— Leon Gussow

Without out doubt a must read for any doctor — it is still relevant. Check out this excerpt on ‘how not to diagnose amyloidosis’.

Dirk Gently’s Holistic Detective Agency by Douglas Adams

“Always difficult to choose the best novel by my favourite author ever. But this, slightly lesser known one, is pretty much perfect. Funny, lots of time bending, intensely well observed, and beautifully worded, has to get the prize, amongst his incomparable joys and gifts to the world.”
— Michelle Johnston

The early death of Douglas Adams was truly tragic. I wish he was still here. All of his books are brilliant – humorous and fanciful, but strangely spot on about the place of us humans in the universe I suspect. This is what happened when Doug met Struan Sutherland.

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

Here’s an overview of this May’s EMU in a highly abbreviated, but still informative form – so you know what to look for.

Editor’s note:
You’ll need to read the full update for all the analysis, criticisms, debates and (of course) the humour.
To read the entire update you can download the original MS word document version here, or you can subscribe to EMU directly via email by sending a message to:
jbleibmd AT yahoo.com

Also, remember to check out previous editions of EMU on LITFL here.

So, what’s in this month’s EMU?

• Cost isn’t the reasons why smokers don’t go to smoking cessation clinics (AEM 18(6)662)
• Yet in an RCT about 1 in 7 smokers give up at 3 months – but is this the real world? Are most people happy smoking? (ibid 18(6)575)
• If you’ve already given a kid with egg allergy propofol, don’t worry badness is unlikely to happen (Anest Anlag 113(1)140)
• Read the full version of EMU to see if any head gaskets are blown in this review of a paper titled “Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 European National Societies of Anaesthesia.” (Eur J of Anaes 28(8)580).
• However, we’re allowed to use ketamine…  (Anesthesia 68(8)653) “Can’t anesthesiologists go back to what they do best – that is raising and lowering tables?”
• Nice idea – let patients, not lawyers, drive the informed consent process. Is it good enough for the real world? (ibid 113(1)13).
• Three questions (what are my options? what are the benefits and harms? and how likely are these?)  improved information given by family physicians and increased physician facilitation of patient involvement (Pat Ed Counsel 84(3)379)
• Doctors communicate differently when disclosing errors (in a simulation) – is this a good thing? (Pat Ed Counsel  84(3)344)
• A sex worker is diagnosed with hepatitis B? You’re the doctor… What do you do? (J Med Ethics 37(10)623)
• Trying to age a bruise by it’s colour is unreliable (Med Sci Law 51(3)170)
• Mean platelet volume is significantly associated with ACS (EMJ 28(7)569) and mortality in decompensated heart failure (ibid p 575)but it’s unclear if it will be of any clinical use.
• Most drunks off the street don’t require ED care, but we have no good way of determining which of the few are sick before they take up a bed (ibid p579)
• Fusidic acid works as well as chloramphenicol eye drops for neonatal conjunctivitis (ibid 28(7)634)
• The patient’s perspective on living with sciatica – do we understand what it’s like for our patients? (Spine 36(15)1251)
• Priapism: many causes, many treatments. Stick a needle in, aspirate, and inject alpha agonists (Urol Clin No America 3892)185)
• Viagara and other low dose PDE5 inhibitors actually prevent recurrent priapism (Urology. 2006 May;67(5):1043-8)
• Young people at low risk for fractures probably don’t need an x-ray before should relocation (AJEM 29(6)609)
• Clean your ultrasound probes – they transmit MRSA (Ann Emrg Med 58(1)56)
• … and your pens too! (Clin Micro Infect 17(6)868)
• Inhaled steroids may help your acute asthma patient (Curr Opin Crit Care 17(4)335)
• Hand washing, and any old surgical mask, help stop respiratory viruse spread ( Cochrane 7:6207)
• Break through pain in cancer patients? Give fentanyl, and lots of it (Curr Pain Head Rep 15(4)244)
• KEtamine is a useful opiate-sparing agent, and might even have anti-tumour and anti-inflammatory effects (BJA 107(2)123)
• An argument that 6mL/kg tidal volumes is not one size fits all in ARDS patients (Chest 140(1)11)
• Topical antibacterial agents: Alcohols are fast acting antiseptics, but wear off quickly.  Chlorhexidine is slower onset but more persistent- a combo is the best idea. Antibiotic creams promote healing but probably not related to their antibiotic properties. (Med Clin No Am 95:703)
• Guess the disease! (Can Fam Phys57:786)
• Headache in the emergency department: a current review ( Curr Pain Headache Rep 15:302)
• Cough suppressants don’t work, and honey, if it does work does do much for coughs in kids (Can Fam Physician 57:435)
• Letters from Greg Henry on Arthur Godfrey’s ukelele teacher, Ken Iserson on NG tubes and IV lignocaine for hiccups, and a question on why we do chest x-ray in suspected PE.
• A myth busting essay on dizziness and vertigo (CMAJ 183(9)1025)
• EMU Roundtable on legal medicine with Greg Henry, Mike Kessler and Rick Bukata.
• EMU looks at the medical problems of marathon runners (AJEM, 2006 24, 608-14)
• Featured article of the month: “Randomized Clinical Trial of Morphine in Acute Abdominal Pain” (AnnEmergMed 2006 48(2)150)

… and what’s not in this month’s EMU?

EMU tends to steer clear of two of the big guns — Annals of Emergency Medicine and the New England Journal of Medicine — because most people see these journals and they’re covered elsewhere. For instance there are these audio productions:

• Emergency Medical Abstracts featuring the legendary Jerry Hoffman and Rick Bukata (subscription needed)
• Annals of Emergency Medicine monthly podcast featuring the also legendary David Newman and Teri Reynolds (free)
• New England Journal of Medicine weekly audio summaries (free)

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

This is a guest post from Dr Toby Fogg, Emergency Physician at Royal North Shore Hospital (RNSH) in Sydney and Retrieval Specialist with CareFlight. This is a follow up to his interview with Minh Le Cong featured in Airway Registry & Checklists in Audio. His website is AirwayRegistry.org.au.

How often does a junior medical officer (or in-fact one of your senior colleagues) in your ED have four attempts at intubating a patient before he, or she, finally succeeds?

How often do patients desaturate during RSI in your department?

Apnoeic oxygenation is all the rage but is it really being utilized?

We think we have a good idea of departmental performance but until we start collecting data on EVERY intubation, we will never have a reliable picture of what we do.

Without this reliable picture, we will never be able to target our education to improve our performance. We will never be able to evaluate new techniques or equipment.

I have been collecting data at RNSH for 2 years now and have data on over 400 episodes of intubation – here are some of the findings:

• Trauma accounts for 30% whilst strokes/ICHs and overdoses account for approximately 15% each.
• 20% occur when an EP is not around to supervise but we don’t have an increased rate of complications out of hours – cudos to the registrars!
• We don’t see many bariatric patients – only 3% had an estimated weight >109kgs.
• Our first pass success is 83%, and 87% of these first looks are undertaken by registrars or SRMOs. This doesn’t leave much practice for the specialists – 3 each per year on average! That makes me worry about skill fade.
• We found that the juniors who hadn’t done any time in anaesthetics had only a 50% success rate (and they were presumably given the easy ones to “have a go” on). We felt this was sub optimal and so have developed a credentialing package that involves an anaesthetic term to bed down basic airway skills and then a simulation session to learn to intubate sick patients in ED.
• Our laryngoscopy skills are a bit under par – 23% Cormack and Lehane 3-4!
• Naked intubation has been banned. I’d better explain – bougies (or stylets for the nonbelievers) are mandatory for all. As we have shown (again) that they do improve your chance of first pass success. The difficulty seems to lie in persuading the trainees that a patient who you think is going to be straightforward can easily trick you. Make life easy – optimise your preparation for first pass success.
• Desaturation occurs in 15% but 9% started off 2 attempts.

There are more graphs and data on the website AirwayRegistry.org.au, as well as a copy of the data collection sheet I use.

Since this project was launched onto the blogosphere a few weeks ago the interest has been phenomenal and I would encourage anyone who manages an airway in ED to get in touch with me. I’d be happy to enlist your department as a recruiting site for what I would love to turn into a multicentre database: The ANZEDAR – The Australia and New Zealand ED Airway Registry! (Suggestions for better acronyms gratefully accepted)

Finally I’d like to share a letter written to our DEMT by one of the junior registrars (permission granted). It will ring a few bells for most readers and underlines why it’s not the fancy laryngoscopes that count when the chips are down, it’s the basics that so often make a difference.

“I wanted to let you know about a positive solo experience I had on the ward during an ICU locum night shift at a private hospital. My airway/resus training at RNSH ED played a huge role in helping me to stabilise and save this patient’s life.

It was 0030 hrs in the morning when I was called to see an unrousable patient (who may have been that way for up to ten minutes prior). On arrival in the room I found a 60 yr. old lady with a heavily strapped right shoulder (after a shoulder arthoplasty that afternoon). She was unresponsive and clearly had an obstructed airway (grunting with paradoxical respiratory attempts). Not only was she blue, she was also obese, short necked, and had a small jaw. Her saturations at the time were 44% with HR 70, SBP 150.

I attempted to perform airway maneuvers and insert a Guedel airway – both of which failed to improve the saturations. She had trismus to compound the problem. No nasopharyngeal airways on the trolley. With a bag-valve mask I was able to ventilate her saturations up to 90% but no better (the saturations continued to fluctuate between 85 and 90%). There was significant resistance to ventilation.

A quick glance at the notes showed no significant PMHx and only morphine in recovery + a morphine PCA at the bedside. I gave 2 x200mcg Naloxone doses that failed to improve her GCS.

By this point I had an experienced ICU nurse + two very inexperienced orthopaedic nurses at the bedside helping during the arrest. There were no other doctors on site. I had one of the nurses phone the ICU consultant to let him know I would need to intubate the patient on the ward. He was 30 minutes away so advised to go ahead.

Sweat beads. Wet pits. Full backside of pants. My HR 179. Am now rethinking career choice.

I got a laryngeal mask brought down from the ICU in the event of a failed attempt (another piece of airway equipment not on the trolley). I gave the patient suxamethonium and propofol. The trismus relaxed and resistance to ventilation improved with muscular blockade and I was able move more air – saturations improved to 100%

I stuck a pillow under her shoulders (Toby Fogg trick I think), and then preloaded a bougie with an ETT. The airway was a grade 3 at first view. I manipulated the larynx and was able to see the cords – the ICU nurse was helpful with maintaining that view.

From there I was able to intubate the trachea with the bougie and pass the ETT without obstruction Capnography (old school litmus paper type capnography) was reading positive and saturations improved to 100%.

I took my first breath for the previous minute”

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

Welcome to the superb 64th 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

Free Emergency Medicine Talks

• Haney Mallemat not only receives Joe’s pick of the week – but he also get ours with his talk on Who needs a Central Line? This talk is packed full on all the pearls and pitfalls you need to know about resuscitating the hypotensive septic patient in the ED- and is a must listen to for all ED docs and nurses.

The LITFL Review Top 20 of the Week

Emergency Physicians Monthly.

• Bypass the OR: ECMO in the ED - awesome case presented here on the use of ECMO in a patient with out of hospital cardiac arrest – ground breaking stuff and its were the future of resuscitation is heading.

Emergency Medicine Literature of Note

• Reducing ED Overcrowding Reduces Mortality - Highlights some of the work being done to improve access block and improve the flow and journey of patients through the ED, with a bonus positive effect on mortality and morbidity!

The LITFL Review Shout Out of the Week

The Short Coat

Being a medical student these day’s is a tough few years, but is it easier these days with the amount of blogs and online resources these students have available to them? This weeks shout out goes to The Short Coat a blog by Lauren Westafer who is a medical student’s attempting to integrate clinical tidbits and cases from the wards and literature, with an emphasis on Emergency Medicine, and she also seems to be a big fan of LITFL.

Check out some of her post below:

• Fellow Students, Lend Me Your Ears – EM Oriented Podcasts
• I See Right Through You – Intro to EM Ultrasound

 Twee-D and Twitical Care

"If you need surgical airway, you have to do it before the patient is dead" Jim Ducanto via PHARM @rfdsdoc

May 20, 2012 2:06 am via Twitter for iPadReplyRetweetFavorite

@MDaware

Seth Trueger

News from the Fastlane

• LITFL has joined forces with Emergency Medicine Australasia were we will be hosting short editorial comments on the key papers from each issue of the journal – and encouraging the publishers to allow us access to the full-text version online of these articles.
•  Want to win a Complete Copy of Emergency Medicine Diagnosis and Management Online Version - find out how in Emergency Medicine Mobile App Competition.
• Michelle delivers us another splendid physiology philes with a look at Cell membrane resting potential.

The Final Words

• “Stay Hungry – Stay Foolish”

-Steve Jobs

• “Being the richest man in the cemetery doesn’t matter to me. Going to bed at night saying we’ve done something wonderful, that what matters to me.”

-Steve Jobs

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 a very cool project. How to make an ultrasound simulator on the cheap for use in training scenarios. We’ve already featured the first Australian implentation of this project (The Australian EDUS2 Project) in the 63rd LITFL Review. In yet another great video from SAEM2012, Paul Kulyk and Paul Olszynski the originators of this project tell the world what it’s all about:

Check out the EDUS2 website, where you can access the code, videos and design plans for free — all you need is to provide the hardware.

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

Emergency Medicine Diagnosis and Management 6e has been turned into an eBook on SkyScape Medical resources and will be available on

• Android OS >1.5
• BlackBerry® OS >4.1
• iPhone/iPod Touch  >2.0 and iPad

…so time for another simple and straight forward competition

 In 100 words or less tell us WHICH social media tools are most useful in delivering/discussing/disseminating health and medical education on the web and WHY

The lucky winner will be chosen by the least social media savvy of our guest contributors and receive a free

• TO ENTER: Leave a comment at the bottom of this post
• CLOSING DATE: Sunday 27th May (somewhere in the world)
• WINNER: Announced Tuesday 29th May
• PRIZE: Complete Copy of Emergency Medicine Diagnosis and Management Online Version

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

Life in the Fast Lane has it’s roots firmly in Australia – despite having a Welshman and a Kiwi at the helm!

As such…this year we have been collating short editorial reviews from our local journal – Emergency Medicine Australasia which publishes peer-reviewed articles, reports, reviews and opinions on the research and clinical practice of emergency care.

Emergency Medicine Australasia, with its strong interest in the effectiveness of emergency diagnostic and therapeutic techniques, is the journal of choice for anyone concerned with improving patient care in the pre-hospital and hospital emergency settings. As the leading journal in the specialty of emergency medicine in the Asia Pacific region, Emergency Medicine Australasia is committed to the furthering of scientific research, the support of educational objectives, and the dissemination of information to the emergency medicine community.

We will be hosting short editorial comments on the key papers from each issue of the journal – and encouraging the publishers to allow us access to the full-text version online of these articles. Each issue will be hosted on LITFL (e.g. the resuscitation guidelines, Vol. 24, Issue 1 and Issue 2) will will then be collated on the EMA Journal page on LITFL.

Hopefully these will provide insight into some of the great academic work being performed in the Southern Hemisphere.

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

Recently I wrote about research performed into changing the paradigm of progressive deterioration in multiple sclerosis (MS). The article was based on an Australian longitudinal cohort study which reported remarkable improvements with lifestyle changes.

As anticipated this produced a wide variety of comments and responses ranging from sceptical disbelief, through academic rebuttal to acceptance and confirmation…

Now the group of academics at Overcoming Multiple Sclerosis (OMS) have commenced a major international research project trying to determine which lifestyle factors may contribute to the progression of MS. The study, approved by St Vincent’s Human Research Ethics Committee in Australia, hopes to enrol many thousands of people with MS (PwMS).

PwMS who consent to the study will fill in an online questionnaire about factors related to their lifestyle (eg. diet, exercise, sun exposure, vitamin D, Omega-3 supplementation, stress reduction) and their health-related quality of life, amongst other questions. Over time the OMS group intend to follow this group at yearly intervals to see if there is a relationship between changes in these lifestyle factors and the health of the group.

This information will be analysed to determine which factors best predict the health of PwMS. Potentially this research may answer some of the most vexing questions in MS related to consumption of particular foods and fats, vitamin D and sun exposure, and the influence of meditation on disease progression.

The survey should take around 30 minutes. This may be the opportunity for the MS community to provide real data on some of the more elusive questions about the disease, potentially affecting the health of hundreds of thousands of PwMS in the future.

If you have been diagnosed with MS, and are over 18 years of age and would like to find out more about this important research go to the link below

HOLISM SURVEY LINK

Further reading:

• Health-related quality of life outcomes at 1 and 5 years after a residential retreat promoting lifestyle modification for people with multiple sclerosis. Hadgkiss EJ, Jelinek GA, Weiland TJ, Rumbold G, Mackinlay CA, Gutbrod S, Gawler I.  J Neurol Sci DOI 10.1007/s10072-012-0982-4  [PDF Download]
• Effect of a residential retreat promoting lifestyle modifications on health-related quality of life in people with multiple sclerosis. Li MP, Jelinek GA, Weiland TJ, Mackinlay CA, Dye S, Gawler I. Qual Prim Care. 2010;18(6):379-89. PMID 21294980
• Overcoming Multiple Sclerosis [Review] [Website] [Facebook] [Twitter]

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

It is the end of the week – for some people – and time to reward yourself with some audiovisual stimulation, Something to energise your very core…

Visual graphics bring familiar music to life and allow the listener to really ‘see’ the music

Stephen Malinowski experiments with his Music Animation Machine to provide a visual manifestation of timbre, rhythm, tonality, reflection and triadic relationships. His experimental work on demonstrating bowing structure is well demonstrated with his experimental work on Bach Cello Suite No.1 in G, prelude (BWV 1007). In this video we see a ”caterpillar” walking between notes, with the notes highlighted by ”harmonic colouring“. The colour of the caterpillar is a mixture of the color of the current note and the note that was just previously played and the width of the caterpillar corresponds to the loudness.

http://www.youtube.com/watch?v=XziwXVxUdA4

Performed by Vito Paternoster; recording courtesy of Magnatune

If you prefer the full orchestral score then…sit back and relax to this audiovisual extravaganza on full screen.

http://www.youtube.com/watch?v=Qglck7rpI3w

If you enjoyed the audiovisual stimulation – then check out this documentary – A brief history of The Music Animation Machine and related musical explorations of Stephen Malinowski

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

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

Relax it’s Friday!

Oh, you work shifts… never mind, another FFFF is here!

This week we find out how the Spanish health service intends to save 2 billion euros a year, what condition accounts for over 10 million courses of antibiotics each year in the US, and we learn about a clever Dutch physiologist, ego bias and micromorts.

Let’s dive on in…

Question 1

What new law was introduced in Spain in 2011, and is expected to save the Spanish health service over 2 billion euros a year?

Reveal the funtabulous answer!

Question 2

According to the CDC, each year in the United States over 10 million courses of antibiotics are prescribed for what condition?

Reveal the funtabulous answer!

Question 3

What is ego bias?

Reveal the funtabulous answer!

Question 4

In 1903, which Dutch doctor-physiologist developed a string galvanometer to graphically record the changes in electrical potential during contractions of the heart?

Reveal the funtabulous answer!

Question 5

What is a micromort?

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.

Last week we defined funtabulous, this week — as gripping as this avalanche survival story is — we define ‘NOT funtabulous”:

http://www.youtube.com/watch?v=0pSBUXFJXiY

Hat tip to the fantastic blog ScanCrit which featured this video in a must read post on Avalanche Survival.

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