How to Kill a Patient During Airway Management

Airway Management is just that…managing the airway upside down and inside out. Take a quick read of the PDF or listen to EM:RAP’s November MP3 audio podcast called Strayerisms: Fluid Filled Airway. It’ll float your boat.

Correct ET tube placement, but if you tube the esophagus, leave the ET tube in place and use it as a landmark.

According to Dr. Reuben Strayer MD, the author, there are four ways to harm your patient during airway management: failure to oxygenate; failure to ventilate; worsening perfusion; and aspiration. His suggestions are doable no matter where you practice or what resources you lack…remember…your greatest resource is knowledge.

 

 

 

Who Knew? Probably the oldest recovered boat in the world, the Pesse canoe, found in the Netherlands, is a dugout made from the hollowed tree trunk of a Pinus sylvestris that was constructed somewhere between 8200 and 7600 BC. This canoe is exhibited in the Drents Museum in Assen, Netherlands. (Not looking too seaworthy these days.)

 

 

Giving Tuesday

Napo River, Tena, Ecuador. Local means of travel for many doctors and nurses in the Amazon.

Tomorrow is Giving Tuesday…the kickoff to end-of-year and charitable giving.

Please consider making a donation to Techies Without Borders (TWB). Our current project, Continuing Medical Education on Stick (CMES), provides free continuing medical education to doctors and nurses in resource-challenged countries globally. You can donate here or here by clicking the green Donate button.
If you have previously donated this year consider sharing this information via social media and spreading the word.
With gratitude,
TWB Team

Meet Dr. Cristian Carreon, Santo Domingo, Ecuador

Dr. Cristian gives a thumbs up while using the CMES-Pi app to search for medical topics of interest.

Dr. Cristian is a full-time Family Practice doctor at the Centro de Salud Hombro a Hombro Clinic (CSHH) in Santo Domingo, Ecuador. CSHH was established in 2007 and partners with Timmy Global Health during brigades. The clinic has three medical exam rooms, dental room and services, an office and a pharmacy. This small but mighty clinic, staffed by two nurses, one part-time and Dr. Cristian, serves approximately 20,000 patients from the poor urban neighborhoods each year.

Centro de Salud Hombro a Hombro Clinic (CSHH) in Santo Domingo, Ecuador.

Dr. Cristian and his staff have few opportunities or financial resources to attend continuing medical education (CME) conferences in Santo Domingo or Quito. A CMES Raspberry-Pi device was installed in the clinic and using smartphone apps the doctors and nurses can access free CME at the clinic. Every month about 20 new topics are available in Spanish as PDF files.

Ecuador Gets a Slice of CMES-Pi

Dr. Debra Stoner departs this week to install CMES-Pi at two sites and dispense CMES thumb drives at two other sites in Ecuador, including Quito, Santo Domingo, Guangaje, and Tena.

The CMES thumb drives and CMES-Pi give rural doctors and nurses access to cutting-edge continuing medical education (CME). Timmy Global Health, a Techies Without Borders (TWB) partner, works alongside local health providers in Ecuador to provide healthcare in remote regions. The CME is provided free of charge by another TWB partner, Emergency Medicine Reviews and Perspectives (EM:RAP).

Visit TWB Twitter, Instagram and Facebook pages for more photos later this week.

Exercise Induced Anaphylaxis?! You Betcha.

Facial angioedema from allergen exposure. Photo from Wikipedia.

Think you know everything about anaphylaxis? Every see a case of Exercise Induced Anaphylaxis (EIA)? The EM:RAP October podcast called; Exercise Induced Anaphylaxis by Jess Mason MD and Gita Pensa MD will give you hives…or at least goosebumps.

Points to ponder: Is there a relationship to food? Can EIA be fatal? What are the clues to diagnosis? All these answers and more await you in this October EM:RAP podcast.

Who Knew? Professor Charles Richet was a French physiologist who coined the term aphylaxis in 1902. This was later changed to anaphylaxis and his pioneering work in Immunology earned him a Nobel Prize in Physiology or Medicine in 1913.

 

Crash Rapid Sequence Intubation (RSI): Clear the Runway for the Crashing Airway Patient

Twenty years ago I was a volunteer at a small rural hospital. A trauma patient was on the way in and I asked the nurse to prime two IV bags, open the BVM and ETT. She declined and said their policy was not to open supplies until at bedside. I get it…supplies are a resource not to be wasted…but having a dedicated airway kit prepped and ready at the bedside is crucial to RSI success.

The crash airway mnemonic SOAP ME runs down the list of everything you need for a successful Rapid Sequence Intubation (RSI) in the crashing airway patient. EM:RAP’s September podcast of Critical Care Mailbag: The Crash Checklist by Anand Swaminathan MD and Scott Weingart MD should be on everyone listening list.

Review what the mnemonic SOAP ME checklist stands for; how to temporize the crashing airway; how to treat the obstructed airway; and most importantly…tips on how to be ready for any airway headed for a crash and burn.

Heres a quick reference for SOAP ME. What’s in your kit? Leave a comment and start the dialogue.

Photo courtesy of Wikimedia Commons.

Who Knew? William Macewan (1848-1924), a Glasgow surgeon, invented a type of endotracheal tube pictured. He was the first person to use an endotracheal tube to give a patient anaesthetic, in 1878. A tube was placed in the larynx to give the patient a dose of chloroform. These examples are made from steel and brass. They range in length from 210 mm to 80 mm for patients of all sizes.

 

Bone Up on Your Rongeur Skills

EMRAP‘s YouTube channel has a plethora of tutorial videos and today’s recommendation will take less than 3 minutes to view. Take a quick review of how to rongeur a fingertip bone to facilitate skin closure. Added bonus…how to make a finger tourniquet from a glove. View here.

Who Knew? Think of a rongeur as a heavy duty forceps used to remove bone. The word is derived from the French noun meaning “rodent” or the adjective meaning “gnawing”.

To Give Steroids or Not: That is the Question

Steroid molecule. (Wikimedia Commons)

In Hamlet Act 3, scene 1, Shakespeare wrote; “To be, or not to be: that is the question”. Hamlets most famous soliloquy is both memorable and intriguing because he was contemplating profound ideas. Something you do every day, every shift and every hour while working…you contemplate decisions based on best practice, cutting-edge articles, and new research. One such question has haunted us for decades…to give or not to give steroids to septic patients.

Take a listen or read the August EMRAP article titled: Critical Care Mailbag: Steroids for Septic Patients by Anand Swaminathan MD and Scott Weingart MD for a fresh perspective.

On Jan 19th, 2018 the ADRENAL Trial results were published trying once and for all to answer the question of adjunctive steroids in septic shock. Take a look at this condensed version.

Rheumatoid arthritis (Wikimedia)

Who Knew? In 1948 the first patient with rheumatoid arthritis was treated with cortisone.  Between 1954 and 1958 six synthetic steroids were introduced for systemic anti-inflammatory therapy. By 1960 all of the toxic effects of chronic corticosteroid administration had been appreciated. In the 1970s the introduction of methotrexate helped restrict the dosages and indications for corticosteroids in the rheumatic diseases.

 

 

Testicular Torsion – A Convoluted Case

What do Chubby Checker and testicular torsion have in common? (Wikimedia photo)

The 14-year-old male patient complained of right lower quadrant pain which varied in intensity for 1 day. He denied nausea, vomiting or fever. The abdominal exam revealed bowel sounds and mild tenderness to palpation in the right lower quadrant without rebound. His abdominal ultrasound was inconclusive; the white blood cell count mildly elevated, and the urine microscopy normal. He was admitted for observation. Twelve hours later the patient developed a fever and severe groin pain. A genital exam revealed classic findings for testicular torsion. The testicle was not salvageable. Unfortunately, the patient was born monorchism and rendered sterile by the orchidectomy. The lesson from this case: always include a genital exam in patients with lower abdominal pain.

Can you rely on the history and physical exam to rule out testicular torsion? Is the testicle salvageable after 6 hours? Wrench yourself away from your music downloads and listen to the EM:RAP August podcast called Testicular Torsion by Rob Orman MD and Larry Mellick MD. Get an update and review on this twisted entity and you won’t spiral out of control when faced with the possibility.

Who Knew? “The Twist” is an American pop song written and originally released in 1959 by Hank Ballard and the Midnighters. It was made popular by Chubby Checker, an American rock n’ roll icon, who put his stamp on the song with the twist dance style.

So what do Chubby Checker and testicular torsion have in common? As Mr. Checker said, “Come on let’s twist again…”. Testicular torsion pain can come and go.