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)
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.
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.
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.
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)
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.
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.
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)
Pregnant graffiti in Lebanon (Wikimedia)
According to an excerpt from Randi Hutter Epstein’s book Get Me Out: A History of Childbirth From the Garden of Eden to the Sperm Bank, five hundred years ago a folk healer advised Catherine de Medici, then the queen of France, to drink mare’s urine and bathe in cow manure to increase her chances of getting pregnant. And she did it. Fortunately, you won’t need mare’s urine to treat pregnant patients with sepsis. But you will need to listen to the March EM:RAP podcast or read the PDF called Sepsis and Infections in Pregnancy by Stewart Swadron MD, Gillian Schmitz MD, Rachel Bridwell MD and Brandon Carius PA.
What are the most common infections seen in pregnancy in your region? Are vital signs good indicators during maternal and fetal resuscitation? If you don’t have much time there are five quick Take Home Points for a 30-second read.
Who Knew? Some of the earliest women’s health books were written by monks…although they would not be my first or even seventh guess as authors. One of the most popular monk guides, Women’s Secrets, or De Secretis Mulierum, has been translated from the original text into modern language by Helen Rodnite Lemay, a medieval scholar.
Perikles Kakousis, weightlifting Olympic champion. St. Louis Olympic Games, 1904. Wikicommons.
Procedures form a structural competency in our medical practices. There’s a satisfaction that goes with a well-executed procedure be it placing a chest tube or realigning an ankle dislocation. There are some bread and butter procedures we do weekly such as intubations to those that call for our expertise rarely such as a cricothyroidotomy. So how do you get your game plan on with the rarely performed procedures? Take a listen to the EM:RAP March podcast or read the pdf called Procedural Competency by Mel Herbert MD and Jestin Carlson MD for quick suggestions on how to stay on top of rarely performed procedures. You’ll be a procedural champ and win the game.
Who Knew? The most widely accepted inception date for the Ancient Olympics is 776 BC; this is based on inscriptions, found at Olympia, listing the winners of a footrace held every four years starting in 776 BC. Tradition has it that Coroebus, a cook from the city of Elis, was the first Olympic champion. (Wikipedia)
I’m looking at cases to post and found one that could be me…because I’m over 60. Here’s the lowdown: over 60 years old with sudden vision loss? over 60 years old with transient vision loss? over 60 years old with transient double vision? Think Giant Cell Arteritis and take a listen to the March EM:RAP podcast: Giant Cell Arteritis by Ilene Claudius MD and Edward Margolin MD.
Or take a quick look at the PDF and bring home the take home points…it’ll make you a giant in the know.
Who Knew? Tales of giants are found in many cultures. The word giant, first attested in 1297, was derived from the Gigantes (Greek: Γίγαντες) of Greek mythology. (Wikipedia)
Dorothy’s original ruby slippers (Wikicommons)
Neonatal stools are a source of concern for parents and color changes can trigger a visit to the emergency department or outpatient clinic. What colors raise your index of concern for serious pathologies such as necrotizing enterocolitis, malrotation with midgut volvulus or intussusception? Plug in your thumb drive or roll out your CMES app and take a listen to Jess Mason MD and Jason Woods MD as they discuss the EM:RAP podcast called Neonatal Stool Rainbow. You won’t find the Wizard of Oz but you’ll take home some knowledge…even without your ruby slippers.