TO BEING DOCTORS-TO-BE

A Must Read for every Practising and Aspiring Doctor …

Mrigank Warrier's Blog

We who were always overachievers. Who missed the dusk of our adolescence solving multiple-choice questions.

We who began our adult lives spending alternate days with corpses. Who carry bones in our bags and books that break our backs. Who spend the prime of our youth in the grime of wards. Who have already witnessed a lifetime’s share of deaths. Who learn about depression but fail to recognise it in ourselves.

We who have no definite college hours. Who don white coats even in the heat of May. Who are accustomed to the deadweight of stethoscopes around our necks. Who will pursue likely teachers for a lesson even into the night.

We who also study law, sociology, psychology, entomology, nutrition, sanitation and statistics. Who are always between exams. Who neglect the pursuit of our other passions. Who sometimes cancel our own vacations. Who covet amphetamines.

We who touch people slathered with…

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Please go to the updated site:

littlemedic.org

For the latest and up to date posts and more!

Airway Trolley Design

Airway Trolley Design at PHARM

Check it out!
.

Oral Conception!!!

Oral Conception via the proximal gastrointestinal tract in patient with aplastic distal vagina…
Click Here for the Article

No Frig’n Way!!!

Prophylactic Anti-Emetics in Trauma – aka “Prevention of Post-Traumatic Mopping Episodes”

Check out: Prophylactic antiemetics in trauma.
A review by Dr Jason Bendall MStJ – Medical Director for the Ambulance Service of NSW in Australia.

I’ve had the privelage of once working under Dr. Bendall (who began as a paramedic, then became a doctor and has now also completed a masters and PhD in clinical epidemiology) in a voluntary first aid capacity and have witnessed that his presence and knowledge as well as relaxed manner inspires respect and warmth in patients and colleagues alike.

This review looks at the use of anti-emetics in trauma patients.
Ondansetron and Metoclopramide were administered prophylactically to  patients. The study enrolled 196 adult trauma patients.

With an endpoint of decreasing nausea, there was a 56% decrease in nausea with the use of anti emetics and a number needed to treat of 2!

With the endpoint of preventing emesis, the use of anti-emetics prevented 9% of patients from vomiting, a NNT of 12.

The study conclusions were as follows:
“Prehospital nausea and vomiting are more common in our cohort of trauma patients than the reported rates in the literature for nontrauma patients transported to hospital by ambulance. These symptoms were associated with female gender, older age, weight, and greater ISS. Our results suggest that antiemetics may be underused in trauma patients, both for prophylaxis and the treatment of active symptoms”. 

Check out Dr. Bendall’s Blog at http://drjasonbendall.wordpress.com for some insightful articles and studies by a giant in the field of advancing EMS, pre-hospital care, EBM and the role and scope of paramedics in Australia and also worldwide.

Cheers 🙂

 

THE VORTEX IN ACTION – RSI IN ED from PHARM

THE VORTEX IN ACTION – RSI IN ED.

I absolutely LOVE this concept!!
The Vortex is an airway decision making algorithm for difficult airway management created by Dr Peter Fitz,  an Emergency Physician and Dr Nicholas Chrimes,  a Consultant Anaesthetist.

“Vortex is different. Its 3 D! Not linear..its circular. Thats cool. Its Non Surgical airway pillars ( tracheal intubation, laryngeal mask airway and bag/valve face mask) are all considered equal and the goal is Alveolar oxygen delivery ( AOD). They even support needle cricothyrotomy”
-Dr Minh Le Cong @ PHARM

Check out the above video demonstrating the Vortex in action AND also this interview on PHARM by Dr. Minh as he discusses vortex with it’s creator’s.

Show me the Evidence! – The NNT Strikes Again!

The NNT would have to be my all time #1 site when it comes to appraising the positive and negative statistical aspects of treatments in the EBM arena.

Here is a small quick-list of Emergency/Acute Care therapies straight from the awesome team at The NNT with their colour grading system included:

• Thrombolytics for major Heart attack (STEMI):   [Page]
  • NNT = 43 against mortality, 
  • 2.3% saw benefit by being saved from death
  • 97.7% saw no benefit
  • 0.7% Harmed by Major bleeding within 6 Hours
  • 0.4% harmed by hemorrhagic stroke 
• Immediate Aspirin for STEMI:  [Page]
  • NNT = 42 against Mortality
  • 2.3% benefit by being saved from death
  • 97.7 saw no benefit
  • 0.6 were harmed by minor bleeding event (anemia – did not require transfusion)

• Mild Therapeutic Hypothermia for Nuero-protection after CPR:  [Page]
  • NNT = 6 against Mortality
  • 16% saw benefit by neurologically intact survival
  • 84% saw no benefit
  • 0% were harmed

• Prophylactic antibiotics for simple hand Lacerations:  [Page]
  • NNT = N/A
  • 100% saw no benefit
  • An unknown number were harmed by sequellae.

• Magnesium Sulphate IV during Asthma Attack [Page]
  • NNT = 3 for prevented hospital administration) 
  • 67% saw no benefit
  • 33.3% of severe asthmatics saw benefit by being prevented from administration to hospital
  • 0% were harmed
  • 100% of non-severe asthmatics received no benefits no harms from therapy.  

So, that’s just a few of Many reviews, all of which can be found at?
The NNT!

So check out the NNT at http://www.thennt.com

 

Cheers 😀 

Meeting THE ‘Paramedico’

A friend and mentor of mine recently introduced me to Benjamin Gilmour; Paramedic, celebrated Author, and Film-maker/Director of the Book and now Movie Paramedico as well as the award-wining movie ‘Son of a Lion’ (2008) and it’s book ‘Warrior Poets”.

Ben is an intriguing character, prone to an empathetic, considerate tone, sporadic silent musings and a relaxed, conversational attitude that makes him just an all round great guy to talk with.
I found the brief discussion we had fascinating! Topics ranging from the efficacy of Adrenaline in OHCA (Out of Hospital Cardiac Arrest), The role of third party emergency agencies in supplementing EMS for OHCA, Retrieval Medicine, and of course, Ben’s specialty; International EMS.

Having read his book ‘Paramedico‘ TWICE! I must say that I highly recommend it to anyone and everyone, whether you have an interest in EMS, Emergency Medicine or travel, foreign cultures, politics, writing and literature in general or just enjoy a good read, i promise you will be caught up in the tales and tribulations of Ben on his travels.

To quote the book’s blurb: “[Paramedico is] A true and entertaining account of the paramedic author’s adventures working on ambulances around the world, from Mexico to South Africa, via Pakistan and Iceland.”
(I honestly didn’t want to give my own description because it truly wouldn’t do the book justice)

Check out the Book, Movie and movie Trailer here: http://paramedico.com.au/film.html

and Ben’s Own Website: http://benjamingilmour.com/

If you are thinking of buying Paramedico the book, which again, I Seriously suggest, then check it out on Amazon.co.uk and get the Unabridged edition which has an extra chapter on Ben’s Stint in Hawai. (Check it out Here)

Cheers. 😀

[I Do not have any financial interests, arrangements or associations to disclose, the opinions presented are wholly my own, I do not claim responsibility or liability for any legal proceedings that may occur]

Pelvic Fractures

Epidemiology: 

• Pelvic Fractures occur in 5-11% of all major blunt Trauma 
• Early Suspicion, Identification, Management and Triage are critical for good outcomes
• Mortality is between 7-19%. (mortality increases to ~50% in open pelvic fracture)
• The Most Common Mechanism of Injury resulting in pelvic fracture is MVA (Motor Vehicle Accident)

Recognition:

• Springing the pelvis is BAD! don’t do it! (springing to asses for fracture has a specificity of 71% and a sensitivity of 59%, suggesting that routine use of this examination should be abandoned.)
• Instead, pain, MOI and S/Sx should be sufficient indication for management and radiology.
• In this study, 90% of pelvic fractures involved the Pubis along the Rami.
• In the Gonzalez et al‘s study ( Gonzalez R P, Fried P Q, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 2002. 195740.) of patients with GCS 14 or 15, the most common positive finding in patients with pelvic fractures was of the patient complaining of pelvic pain (67% of 97 patients) whereas only 32% had pain on iliac compression and 37% had pain on palpation of the pubic symphysis.

Management:

• This study found an increased benefit with the use of POD’s – Pelvic Orthotic Devices
• Early Surgical Intervention to externally fixate is recommended and improves morbidity and mortality. Article.
• Quality training should be conducted regularly in the application of surgical external fixation. In this study, 47% of external fixators were applied incorrectly, possibly increasing morbidity/mortality!
• Fluid Resuscitation with transfusions is neccasary. (In one study (Rothenberger et al., 1978) of 26 patients who died primarily of pelvic fracture 18 died of exsanguination in the first 9 h)
• This study recommends Boluses of 250 ml normal saline should be titrated until restoration of the radial pulse.These principles are supported by the National Institute for Health and Clinical Excellence in the guideline Pre‐hospital initiation of fluid replacement therapy in trauma.
• New research supporting permissive hypotension, transfusions protocols and management of major trauma is, as expected, the way to go.

References:

‘The prehospital management of pelvic fractures’  

by Caroline Lee and Keith Porter. 

• http://www.ncbi.nlm.nih.gov/pubmed/2746708
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756310/pdf/v019p00494.pdf
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1285697/pdf/archemed00027-0052.pdf
• http://www.sciencedirect.com/science/article/pii/S1072751507001408
• http://www.sciencedirect.com/science/article/pii/0002961085904167
• http://www.sciencedirect.com/science/article/pii/S0002961006002984
• https://jaaos.org/content/17/9/541.abstract
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1397448/?page=4

Pericardial Tamponade – The #FOAM Gods address the “full sack”

It’s the trick-or-treat of trauma
As little Mollie’s bag of candy begins to fill with sweets on Halloween night, you’re stuck in the Emergency Department on the other side of the city with a post MVA chest trauma 40YOM with Dyspnea, Sinus Tach, c/o mild discomfort and bruising around the sternum and left chest.

There is no shortage in the literature and #FOAMed on this one, but after listening to this podcast by Dr. Haney Mallemat on ‘Managing Pericardial Tamponade in the Slowly Crashing Patient’  featured at freeemergencytalks.net I was inspired to re-visit the topic.

It’s a great podcast, around 13 minutes and covers a case study and some many seriously valuable clinical pearls in dealing with Pericardial Tamponade.
A few of my favorite take-home points from Dr. Haney were:

1. Size doesn’t Matter (sound familiar?) – it’s all about timeframe
2. Ultrasound Ultrasound, Ultrasound! – then again, I feel like the entire #FOAM world says that!
3. There is only 1 cure – that’s drainage – everything else is a bandaid solution
4. Don’t expect Beck’s Triad or even Pulsus Paradoxus  to slap you in the face, the pathophysiology doesn’t give a Cra* about traditional presentation – so ultrasound that sucker!
5. Lastly, NO PPV – that includes PEEP, CPAP, BiPAP, even Intubation! and the rest!
   Positive Pressure Ventilation will inevitably cause your patient to crash because it removes the negative pressure mechanism in the intra-thoracic space that is being used to fill the chambers

Now, Here’s what the EM Gods have to say:

• Cardiac Tamponade – from start to finish (great first read) by THE Cliff Reid @ Resus.me ←♥
• ED Thoracotomy: Is It Just The First Part Of The Autopsy?
  By Kane Guthrie @ LITFL
• Does this patient with a pericardial effusion have cardiac tamponade? 
  Rahul Patwari, M.D & Scott Miller, M.D @ emergencyprocrastinator.org on the article by Roy CL, Minor MA, et al
  • EMCRIT’s Scott Weingart on Diagnosis and Treatment:
    The RUSH Exam
    Traumatic Arrest 
  • Apply Some Pressure..? Traumatic Cardiac Arrest 
    by Dr. Natalie May @ StEmlyns

Articles:

Click to access Tamp1.pdf

Click to access EMSProtocols_Aug2011_RevisedOnly.pdf