Advanced Trauma Life Support (ATLS) 10th Edition: Stemming the Hemorrhage of Misinformation

ATLS was a mandatory course during my emergency medicine training with recertification every few years. One of the greatest benefits was recognizing the need to asign a leader and develop a systematic approach to the trauma patient. There is always controvrsy surrounding proptocols and recommendations but the 10th edition is based on decades of trauma experience.

One of the new changes in the shock and circulation section is an emphasis on tourniquets, packing and the application of pressure; some very basic methods that can quickly control hemorrhage. Where do you focus your attention first? Airway? Hemorrhage control?

Wherever you practice and no matter the resources available you will find something in this podcast to strengthen your skills. Take a listen to the September 2019 EM:RAP podcast or read the PDF called: Trauma Surgeons Gone Wild: ATLS 10th edition update by Stuart Swadron MD, Kenji Inaba MD, and Billy Mallon MD.

 

Morell Wellcome tourniquets. (courtesy WikiMedia Commons)

Who Knew? The first recorded efforts to prevent arterial bleeding has been ascribed to Sushruta, the father of surgical art and science, in 600 B.C At that time, he pressed the arteries with pieces of leather that he made himself and it is said that he had used a device in which we now call the tourniquet. (NCBI)

 

 

 

 

Knowledge Translation

 

On September 2, 2019, Dr. Manoj Thomas, President of TWB, and Dr. Vera Sistenich, an Emergency Medicine physician with HandUp Congo, spoke to the Sydney Development Circle about “Knowledge Translation” (KT). The World Health Organization defines KT as: “the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health”.

TWB works in the nonprofit sector under the scope of KT via our Continuing Medical Education on Stick (CMES) Project. It provides health practitioners in remote regions access to up-to-date CME using novel delivery methods, which do not depend on fragile infrastructure. This is assumed to translate into improved clinical practices, self-esteem, and patient outcomes.

However what is the price paid for any intervention when for every action there is a reaction. Dr. Manoj explains, “Given that we have technologies to assist with learning, the real question is about Knowledge Translation and ethical dilemmas around it. However, in reality, there are three barriers: political, cultural/social, and financial constraints.”

In the case of the CMES Project, introducing a product which doesn’t depend on local infrastructure points to the governments deficiencies in providing basic services such as electricity and Internet; a cultural consideration in the DRC is that junior doctors taught a specific medical or surgical technique by the senior doctors are unlikely to contradict their superiors and therefore the introduction of up-to-date CME which challenges long-held beliefs can cause staff internal conflict; and a health practitioner may want to use a product but doesn’t have finances for a smartphone or access to a computer.

We strive to recognize the pros and cons of each CMES Project we launch by working with; local practitioners to identify needs and challenges; local partners engaged in similar work; and local Ministries of Health.
What disruptive consequences have you experienced through your knowledge sharing? What was the relevant ethical issue? Share your story in the comments and help us all understand and work better.

 

 

 

MARCH Home Knowledge on Blast Injuries

Ambroise Paré, on the battlefield using a ligature for the artery of an amputated leg of a soldier.(Photo Wikipedia)

Under the best of situations major trauma centers can be overwhelmed with dozens of seriously injured patients but for many CMES participants limited resources are an everyday reality. The August EM:RAP podcast titled, “Blast Injuries” by Anand Swaminathan MD and Josh Bucher MD will help you piece together triage and treatments for a mass casualty.

Tactical Combat Casualty Care (TCCC) uses the mnemonic MARCH for military battlefield medicine. 

 

 

  • Massive hemorrhage is managed through the use of tourniquets, hemostatic dressings, junctional devices, and pressure dressings.
  • Airway is managed by rapid and aggressive opening of the airway to include cricothyroidotomy for difficult airways.
  • Respirations and breathing is managed by the assessment for tension pneumothorax and aggressive use of needle decompression devices to relieve tension and improve breathing.
  • Circulation impairment is assessed and managed through the initiation of intravenous access followed up by administration of tranexamic acid (TXA) if indicated, and a fluid resuscitation challenge using the principles of hypotensive resuscitation. TCCC promotes the early and far forward use of blood and blood products if available over the use colloids and discourages the administration of crystalloids such as normal saline (sodium chloride).
  • Hypothermia prevention is an early and critical intervention to keep a traumatized casualty warm regardless of the operational environment.

A wounded knight is carried on a medieval stretcher. (Photo Wikipedia)

Who Knew? An early stretcher, possibly made of wicker over a frame, appears in a manuscript from c.1380.

Ambroise Pare (c. 1510-1590) is considered one of the fathers of surgery and modern forensic pathology and a pioneer in surgical techniques and battlefield medicine.

A Honey of an Idea


Meet Dr. Vera Sistenich, an Emergency Medicine physician from Sydney, Australia. Dr. Vera is the Project Leader for HandsUp Congo, an Australian nonprofit, “Building a Healthy Congo” Project. In collaboration with local partners and the Democratic Republic of Congo’s (DRC) government they are committed to bring Emergency Medicine training and integration to the DRC healthcare system. This is her story on one way she supports their goals.

“I started in 2015 when I lived in a seaside suburb here in Sydney called Coogee. As a child, I grew up in Hong Kong (my Mum is Chinese) but our family spent our summer holidays in Germany (my Dad is from Munich). We had a very rural home in a Bavarian suburb next to a forest. Our neighbour, an old man, used to keep his hives in the forest which I used to pass walking our little sausage dog daily. I was always fascinated, and we could see the old man at night through the window processing wax and honey. I thought to myself as a girl I’d love to keep bees one day. When I moved to Sydney and bought my own home for the first time, I came across The Urban Beehive, a business and movement promoting responsible beekeeping in the urban environment. The owners Doug Purdie and Vicky Brown are Australian beekeeping royalty now! I did a course with them and then started my own hive in the outdoor area of my ground floor unit in Coogee.

The weather here is so good that my one hive was producing around 100kg of honey a year. There are only so many birthday and Christmas presents you can make with all this honey! This volume would give around 300 jars a year, so I tried my hand at a little social enterprise, creating a label called “Coogee Bees for Congo” and selling each jar for AUD $15 and putting all the profit towards our Congo EM Project. There is a famous building in Coogee right by the beach called The Coogee Pavilion. It has a blue and white dome, which is what inspired the blue and white bee of my label, set within the contour of the landmass of the DRCongo. I changed the sting of the bee into a little heart, a reminder to myself of our duty to translate compassion into practice towards those in need everywhere. 

I now have 2 hives, producing about 200kg per year. I have raised over AUD $ 10,000 since the start of the project with the honey.

Beekeeping is very successful in the city. The Sydney Bee Club, of which I’m a committee member, has partnered with several universities here for research, providing dead bees and honey samples from our members from numerous suburbs. It turns out that the honey produced in cities is less contaminated with chemicals and pesticides than a lot of rural honeys and the flavours more complex due to the diversity plants and lack of monocultures in the urban setting. Heavy metals from the city environment are stored within the bodies of the bees themselves and secreted somewhat into the wax, but not into the honey. This came as a big and welcomed surprise to us all. Challenges, though, included minimising swarming in the urban environment so our hives don’t become a public nuisance, and adhering to rules and regulations regarding safety towards our neighbours. The practice is popular here and encouraged by our local counsellors. 

I don’t do any formal marketing as such. I work at two hospitals here in Sydney and just by word of mouth, colleagues, family and friends buy out the honey every time. I post on Facebook when I have a new batch and also on the HandUp Congo Facebook page. I also make candles from the wax as gifts.

In addition to raising funds for the EM project, one year, we chanced upon the only beekeeper training collective in the whole of the Congo whilst traveling to one of our teaching sites by road. From that, a completely separate Be A Honey Project was born – we have raised funds to bring these experts to the remote village of Lotumbe, where Lucy of HandUp Congo grew up, to train them in sustainable beekeeping, in particular to empower the Pygmy population there.”

What’s the Buzz About Honey?

Manuka honey (Wikipedia)

The May edition of Emergency Medical Reviews and Perspectives (EM:RAP), your CME sponsor for the Continuing Medical Education on Stick (CMES) Project, has an article on the use of honey in the emergency department or outpatient clinic. The commonly known medical uses for honey include cough suppression and skin wound antibacterial agent. Other uses that can be life saving are cited in the article titled, Honey for Everything by Ilene Claudius MD and Sol Behar MD. Buzz on over to your thumb drive or CMES-Pi and take a listen or read. It’ll sweeten your day.

 

Five-petaled white flowers and round buds on twigs bearing short spiky leaves. A dark bee is in the centre of one of the flowers.

Manuka bloom (Wikipedia)

Who Knew? The antibacterial effects of honey vary widely depending on the type and production location as cited by Willix et al. of the University of Waikato in New Zealand. Manuka honey found in New Zealand is reported to have high antibacterial activity.

 

CMES-Pi Participant Highlight: Mount St. John’s Medical Center, Antigua

Meet Dr. Vonetta George who works at Mount St. John’s Medical Center (MSJMC) in Antigua. Dr. Vonetta works in all critical care areas of the hospital including supervising the 15 doctors and 2 dozen+ nurses in the Emergency Department.

Antigua is located in the West Indies, a Leeward Island in the Caribbean. Mount St. John’s serves the population of Antigua and also Barbuda. Working on an isolated island directly affects the doctors and nurses ability to access current continuing medical education in a cost effective manner. Dr. Vonetta was the gail force hurricane behind getting the CMES-Pi Project installed in her hospital. MSJMC installed a CMES-Pi in June last year. Using our smart phone apps the staff can look up CME current practice topics at bedside. The CME is provided by our partner Emergency Medicine Reviews and Perspectives. The PDF files provide helpful bullet points and take seconds to read. The MP3 files are providing topics for weekly group CME conferences and discussions. The CMES-Pi Project directly impacts access to CME for 101 doctors and 179 nurses at the hospital. Thank you Dr. Vonetta!

Who Knew? The first inhabitants were the Siboney, who can be dated back to 2400 BCE. Arawaks settled subsequently, around the 1st century CE. The Caribs arrived later, but abandoned Antigua around the 16th century, due to the shortage of fresh water. Christopher Columbus sighted the larger island in 1493, and named it after a church in Seville, Santa Maria de la Antigua. (Commonwealth)

Congestive Heart Failure: Bring on the Leeches?

Wikimedia photo.

The April edition of Right on Prime covers everything you need to know about congestive heart failure from the definition to palliative care, including advice on therapeutic phlebotomy. No matter where you practice you will find breath-taking take home points. Take a listen or read: The Generalist: Acute and End Stage CHF in the ED by Vanessa Cardy MD, Mel Herbert MD, and Heidi James MD in the April edition of Right on Prime available to all CMES participants using either the CMES thumb drive or Pi.

Leech application tubes and blood letting tool, probably from 1800s. Photo from Wikimedia.

Who Knew? Bloodletting (or blood-letting) is the withdrawal of blood from a patient to prevent or cure illness and disease. Bloodletting, now called therapeutic phlebotomy, whether by a physician or by leeches, was based on an ancient system of medicine in which blood and other bodily fluids were regarded as “humours” that had to remain in proper balance to maintain health. It is claimed to have been the most common medical practice performed by surgeons from antiquity until the late 19th century, a span of almost 2,000 years. (article content from Wikipedia)

C3: Psychiatric Emergencies Part 2

Wikimedia image.

Last week I introduced you to C3, Continuous Core Content, the newest medical education available to all CMES and CMES-Pi participants. The March C3 content is part two of psychiatric emergencies covering depression, anxiety and eating disorders. You can access the C3 folder with the thumb drive or the smartphone apps using the CMES-Pi.

Do you know what endocrine disorder can mimic depression or that pulmonary emboli can present with a common and misleading psychiatric complaint? A quick read of the Take Home Points will lift your spirits and lessen your anxiety when faced with a psychiatric emergency.

Who Knew? Psychiatric illness were recognized over 4000 years ago In the second millennium B.C. in Mesopotamia where there are written accounts of depression. It was thought to be a spiritual condition and therefor treated by priests instead of healers.

Introducing C3: Continuous Core Content

Photo from Wikimedia.

WooHoo…C3 is here for your listening and viewing pleasure! EM:RAP has generously provided Techies Without Borders their C3 content to add to our cloud based server. This CME content is available to participants using either the thumb drive (USB) or Raspberry-Pi access options. It will be in a separate folder and you can use the Search for specific topics.

C3 is a clinical based review on how to assess and treat common and grave Emergency Department and Urgent Care complaints. It’s ideal for all practitioners wanting to review the basics efficiently and quickly. Think of it as your basic Lego set.

The same great MP3 and PDF formats are available. The audio file contains a focused summary at the end of the talk, so if you are short on time you can fast forward. The PDF files start off with the all important Take Home Points for a quick update. You can also test your knowledge with the uploaded questions and answers.

Build up or reinforce your basic knowledge with C3. Thank you EM:RAP.

Who Knew? “The Lego Group began in the workshop of Ole Kirk Christiansen (1891–1958), a carpenter from Billund, Denmark, who began making wooden toys in 1932.[7][8] In 1934, his company came to be called “Lego” derived from the Danish phrase leg godt [lɑjˀ ˈɡʌd], which means “play well”.” (Wikipedia)

 

 

Aneurysms: It’ll Blow Your Mind

Abdominal aorta MRI. (Wikimedia)

Practicing in rural and remote regions globally with limited staff and resources poses challenges not faced by your colleagues in larger cities and academic centers. Case presentations from those working in rural regions help us understand the restrictions, challenges, and downright genius solutions from treating to to saving a life. I find these stories uplifting, invigorating, and deserving of a standing ovation.

Take a listen or read about The Case of the Man with the Aneurysm by Vanessa Cardy MD and Mel Herbert MD in the EM:RAP April files. It’ll expand your knowledge.

 

Who Knew?

On 17 April 1955, Einstein experienced a ruptured abdominal aortic aneurysm, which had previously been reinforced surgically by a surgeon in 1948. He took the draft of a speech he was preparing for a television appearance commemorating the State of Israel’s seventh anniversary with him to the hospital, but he did not live long enough to complete it. Einstein refused surgery, saying, “I want to go when I want. It is tasteless to prolong life artificially. I have done my share; it is time to go. I will do it elegantly.” He died early the next morning at the age of 76, having continued to work until near the end. (Wikipedia)

 

1 2