Covid-19 Information on CMES Server from WHO & EM:RAP

CMES participants…you will find EM:RAP Corependium chapter & WHO Covid-19 information for USB and Pi users on the TWB server. Topics range from Hand Sanitizer Formulation to Critical Preparedness. We will update frequently, so check back weekly.
A reminder from our partner in the DRC, HandUp Congo,
“A South African word, Ubuntu describes our recognition that we are all bound together in ways that can be invisible to the eye; that there is a oneness to humanity; that we fulfill ourselves by sharing ourselves and caring for those around us.” Stay well and thank you for being on the frontlines of healthcare.

Cheap Tricks: Isopropyl alcohol inhalation

Treat nausea with a cheap alternative to oral, intramuscular or intravenous medications? Yes, you can. This article, “Inhaled isopropyl alcohol for nausea and vomiting in the emergency department“, by Adrienne J. Lindblad, ACPR PharmD noted 200 nonpregnant adults presenting to the ED found inhaled (smelling) isopropyl alcohol improved mild to moderate nausea and vomiting.

Have you tried this alternative and low-cost treatment? Sniff out the details. Take a listen or read the February EM:RAP’s Right on Prime Introduction titled: Alcohol Swabs for Treating Nausea by Heidi James MD and Vanessa Cardy MD.

 

Wikimedia.

Who Knew? “The term “rubbing alcohol” came into prominence in North America in the mid-1920s. The original rubbing alcohol was literally used as a liniment for massage; hence the name. This original rubbing alcohol was rather different from today’s precisely formulated surgical spirit; in some formulations, it was perfumed and included different additives, notably a higher concentration of methyl salicylate.” Wikipedia

Ketamine To The Rescue…Or Not

Ketamine model (WikiMedia)

One of my favorite conference speakers has always been Dr. Al Sacchetti from Camden, NJ, USA. He is passionate about Emergency Medicine and understands his patients. So when Dr. Sacchetti goes on a rant…I sit up and listen.

Who doesn’t love ketamine? It’s cheap and available worldwide. Use it for pediatric sedation, status epilepticus, and anesthesia. It can be administered intranasally, intramuscularly and intravenously.

But can it safely be used for agitated delirium? Listen to the October 2019 podcast or read the PDF: Rants from the Community: Ketamine by Al Sacchetti MD. It’s sure to calm your agitation when faced with a delirious patient.

 

 

Who Knew? Ketamine is a drug of abuse. When the drug is diverted for recreational use, the original pharmaceutical form is often abandoned. The most popular method is snorting ketamine powder. The powder is prepared by evaporation of the original solution or ketamine solution may be transferred to a vaporizer to be administered intranasally. As with all illegally sold drugs the concentration and presence of adulterants are mostly unknown and therefore represents a public health risk.

Pediatric Airway: Crash Review

Photo from Wikimedia.

Most of us are anxious about taking care of infants and children younger than 2 years old who need airway support. It’s intimidating and challenging to face a small airway when most of us face this critical situation only a few times a year. It’s imperative to stay current and review the procedure and medications regularly. The September EM:RAP C3 podcast on Pediatric Airways hits all the vital landmarks for troubleshooting and management. Expertly presented by Jessica Mason MD, Mel Herbert MD, and Stuart Swadron MD, you will take home points such as; Infants and children have a much smaller pulmonary reserve than adults; thus they desaturate much more quickly after preoxygenation. More empowering take-home points await you so take a listen and share the knowledge.

Photo from Wikimedia.

Who Knew: Dr. Crawford Long administered the first documented ether anesthetic to an 8-year-old boy for a toe amputation on July 3, 1842.

 

 

Every Village and Every Health Practitioner

Dr. Christian, Santo Domingo Clinic, Ecuador

We are passionate about the Continuing Medical Education on Stick (CMES) Project which delivers cme to hundreds of medical practitioners globally. We couldn’t do this without the generous in-kind donation of the cme content from our sponsor, Emergency Medicine Reviews and Perspectives (EM:RAP). Mel Herbert, EM:RAP CEO, shared his philosophy in this article.

Thank you, Dr. Mel, for your foresight and wisdom.

Who Knew? “Europe’s formal medical education system started in the late Middle Ages, with the rise of the universities in what is now Northern Italy. From approximately ad 1100 until the mid-19th century, two tiers of medical practitioners existed: (1) academic doctors and (2) practically trained surgeons (which consisted of a motley collection of practitioners, including barber–surgeons, traveling practitioners, ship’s surgeons, tooth extractors, etc.).” Read the full article here.

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.

 

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