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    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

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  • Thumbs Up Nigeria

    Meet Dr. Dare Ogunlusi from Ekiti State University Teaching Hospital in Nigeria. He is an attending in the Department of Accident and Emergency. He is the newest recipient and participant in

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  • Time to Charge Your Battery…

    With a jolt of information on button battery ingestions by pediatrician Ilene Claudius. The November 2017 EM:RAP edition has a podcast sure to shock you. From one end of the

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  • Changing the World One CMES at a Time

    Greetings CMES Users, This blog is your educational arena. Tell us about yourselves, where you work, the challenges you face in your practice and how CMES is helping you meet

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Potassium: An Element to Love

Photo courtesy of Wikimedia Commons.

Ever chase a patients potassium? Of course, you have…we all have nibbled our fingernails over the ever-changing potassium. So when do you worry? Here are a few questions to contemplate: true or false?

Hypokalemia is associated with hypomagnesemia.

Encourage repletion with potassium-rich foods rather than pills.

The total body deficit is always more than you think.

If the potassium is less than 3.0 meq/L and the QTc is approaching 500 msec, the patient should be admitted for repletion.

Tune into the August EMRAP podcast called: Electrolyte Emergencies – Part 1: All Things Potassium by Rob Orman MD and Corey Slovis MD for the answers.

Who Knew? Potassium was the first metal that was isolated by electrolysis by Sir Humphry Davy in 1807.

EMS in Nepal – Meet Dr. Sanjaya Karki

Dr. Sanjaya greets an opiod overdose patient transferred from a remote district in Nepal to Medicate Hospital, Kathmandu.

Dr. Sanjaya Karki at Mediciti Hospital, Kathmandu Nepal, has been using the CMES thumb drive since 2016. He is a regular reader of this blog and uses the EMRAP cme to prepare lectures along with keeping his knowledge up-to-date. Dr. Karki is the Medical Director for the Department of Emergency Services at Mediciti. He did his MBBS and European official double masters in health and welfare and has done his MD in Emergency Medicine. Well known in Nepal and internationally for his innovation in EMS, he was honored and awarded the David Well Extreme Medicine Award, UK in 2014 and the EMS10 Innovators of The Year 2016 Award, USA.
Dr. Karki shares his insights about the fledgling EMS program in Nepal. “The EMS Helicopter emergency medical service is becoming more and more popular and productive in Nepal. Nowadays many voices are raised in order to streamline this service. The major topic at the government level should be to make a strategy and policies governing this important service.
Due to unavailability of road access in many places of Nepal, as well as no proper ground EMS service available across the nation, Helicoptor EMS will surely play a pivotal role in preventable deaths.”
Who Knew? Opioid Misuse Disorder is new to Nepal following on the heels of Cannabis and alcohol addiction. Read this article to find out more.

PreHospital Air Medical Plasma Trial (PAMPer)

Fresh frozen plasma (Wikimedia)

Fluid resuscitation, including type and amount, has been scrutinized for prehospital care of trauma patients. This recent multi-center study demonstrated remarkable results. The abstract is reproduced from the NEJM website:

The New England Journal of Medicine

Abstract

BACKGROUND

After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting.

METHODS

To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days.

RESULTS

A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, −9.8 percentage points; 95% confidence interval, −18.6 to −1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan–Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients’ arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury–acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions.

CONCLUSIONS

In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427.)

Who Knew?

Two vampires walked into a bar.

The bartender said, “what will it be?”

The first vampire said, “I’ll have a blood.”

The second vampire said, “I’ll have a plasma.”

“Right”, the bartender replied, “one blood and one blood lite.”

 

 

Meet Dr. Samrat in Nepal

Dr. Samrat graduated from the Peoples’ Friendship University of Russia in Moscow and earned his post-graduate degree in General Practice and Emergency Medicine from Tribhuvan University Teaching Hospital in Kathmandu, Nepal.
After working in Patan Academy of Health Science and Kathmandu Model Hospital, he joined CIWEC Clinic and Hospital in Kathmandu a few years ago. CIWEC is a travel medicine facility that cares for patients with a variety of travel-related and general health issues. Dr. Samrat describes his practice: “We deal with common issues like common respiratory illness, gastrointestinal illness and also rare and complicated issues requiring prolonged hospital care or care in the intensive care unit. We look after both outpatients and inpatients.  We help people with their travel needs including vaccinations and recommendations for their specific travel plans.”
Despite having access at CIWEC to UpToDate, a point of care medical information site provided by his employee, he uses the CMES thumb drive to access up-to-date cme at home. He likes having this option because “…the CMES thumb drive has helped me a lot while dealing with these issues. This has also given opportunities to interact with colleagues for the improvement in the overall care of our patients.”
Who Knew? The national flag of Nepal (Nepali: नेपालको झण्डा) is the world’s only non-quadrilateral national flag. The flag is a simplified combination of two single pennons, known as a double pennon. Its crimson red is the color of the rhododendron, Nepal’s national flower, while the blue border is the color of peace.

Guatemala Gets a Slice of CMES-Pi

Dr. Manoj Thomas visited Timmy Global Healths partner Asociacion Pop Wuj Clinic in Xela, Guatemala this past March. Asociacion Pop Wuj is a collectively owned, non-profit, Spanish language school that promotes community development through a variety of programs including a daycare center, construction of safe stoves, reforestation and ecological education, a student scholarship program, and a comprehensive health and nutrition program.

Working with Dr. Carmen and Dr. Herman he set up a CMES-Pi at the Xela clinic. The regular access to up-to-date continuing medical education content for the staff is welcomed as travel to conferences is difficult and costly for the organization.

We welcome Asociacion Pop Wuj and there impressive work in the community.

The Pop Wuj team with Dr. Manoj Thomas (on right).

The Pop Wuj team tries out the CMES-Pi connectivity.

Emergency Severity Index: The Ups and Downs of Triage

Who’s next? (Wikimedia Commons)

Jessica Mason MD and Wendy Chan MD discuss the history and present methods of triage in the May EM:RAP podcast of Annals of Emergency Medicine: Emergency Severity Index.

How do you risk stratify in your emergency department? Do you use a three-step system of emergent, urgent or non-urgent? Or the five-step triage protocol with ESI 1 indicating a critical patient to an ESI 5 indicating nothing serious? Neither provide an ideal system, but what about front-end physician triage, split flow and vertical flow? Update your triage knowledge by listening to the podcast…it might make your day flow smoother.

Larreys Flying Ambulance (National Library of Medicine)

Who Knew? Baron Dominique Jean Larrey is credited with inventing triage during the Napoleonic Wars but did you know he invented the first ambulance? The horse-drawn “flying ambulances” could maneuver quickly across a battlefield delivering injured men to field hospitals.

Thumbs Up Nigeria

Meet Dr. Dare Ogunlusi from Ekiti State University Teaching Hospital in Nigeria. He is an attending in the Department of Accident and Emergency.

He is the newest recipient and participant in CMES. Techies Without Borders (TWB) was referred to Dr. Dare by his friend and colleague Dr. Lisa Charles from Victoria Hospital in St. Lucia. TWB mailed a thumb drive to Dr. Dare after discussing the cme options that would best work for him. He will be testing the thumb drive and providing feedback on usability and content for his specific location.

CME development and utilization face challenges worldwide because resources are limited and infrastructure for the delivery of healthcare and information is fragile. Feedback from locations around the globe helps us improve our services and products. If you have colleagues who would be interested in either CMES or CMES-Pi, please contact Dr. Debra Stoner at: deb.twb@gmail.com

Gastric Lavage: Yes or No?

Antique gastric pump.
(Wikimedia Commons photo)

According to an EMRAP article, orogastric lavage was considered a standard procedure. It has never been proven to be of benefit. There are no recent studies. Although it was thought that removing the gastric contents might decrease the severity of the overdose, this is probably not the case. Why? Listen to the podcast or read the bullet points of the May 2018 article called “Pumping the Stomach” No More, by Anand Swaminathan MD and Sean Nordt MD, PharmD.

Do you still lavage for poison overdose? What substances? Leave a comment and share your knowledge.

Who Knew? Unlike many of our simpler medical and surgical instruments, mention of the stomach and duodenal tubes is not to be found in the classical writings of the ancient Greek and Arabian physicians…the somewhat uncertain origin of the stomach tube may be placed at about 144 years ago. Precursors of the stomach tube, however, were in common usage as early as the days of Imperial Rome. (Annals of Internal Medicine; The History of the Invention and Development of the Stomach and Duodenal Tubes by John R. Paine, MD)

 

 

 

Leeches: Friend or Foe

Leech
(WikiMedia Commons photos)

My experience with leeches is limited to a profound fear while hiking during the Nepal monsoon season where the rainforest leeches drop from the vegetation and make you their personal smorgasbord.

Have you ever used a leech medically to reduce swelling and vascular congestion? How do you remove leeches? How do you treat the wounds? Leave a comment and share your skills with us leech-less colleagues.

Who Knew? Leeches have 32 Brains. Their internal structure is divided into 32 segments. Each of these 32 segments has its own segment of the brain. Every leech also has two reproductive organs and 9 pairs of testes.

The Long & Short of Neck Injuries

Giraffe (WikiCommons photo)

Blunt neck trauma can be an airway nightmare. Listen to the podcast or catch the bullet points about workup and treatment from the May 2018 EMRAP article by Mel Herbert MD and Billy Mallon MD called Blunt Neck Trauma.

Who Knew? A giraffe’s neck is too short to reach the ground. It spreads its front legs or kneels to reach the ground for a drink of water.

 

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