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    Giant Cell Arteritis

    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

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    Rural Medicine: Diabetic Ketoacidosis

    Once a month I will comment on the Rural Medicine podcast from EM:RAP. It’s exciting to read CME that can be applied globally no matter where you live or what

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  • Testicular Torsion – A Convoluted Case

    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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Mel Herbert: Keynote Address at ACEP’s 50th Anniversary Meeting

The American College of Emergency Medicine has an annual meeting and this year marked its 50th-anniversary conference in October 2018. Mel Herbert, Founder and Editor of Emergency Medicine: Reviews and Perspectives (EM:RAP) gave the keynote address. EM:RAP partners with Techies Without Borders to bring you monthly CMES and CMES-Pi.

His talk will spark your confidence no matter what type of medicine you practice…but if it happens to be Emergency Medicine…he lets you know how much you rock the world.

 

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.

 

 

Go Fund Me: Give a Slice of CMES-Pi Success

 

The Techies Without Borders team thanks everyone who donated, sent words of encouragement and shared our Go Fund Me page on their social media. We raised $2000 USD in two weeks.

The funding supports installation of CMES-Pi units in Mbarara University of Science and Technology and Makerere University Hospital, Uganda; Mount St John’s Medical Centre, Antigua; Victoria Hospital, St. Lucia; Timmy Global Health (TGH) partner clinics in Quito, Santa Domingo, and Tena, Ecuador; and USB drives TGH’s Guangaji Clinic, Ecuador.

Who Knew? TWB slowly formed as two university professors, Dr. Manoj Thomas and Dr. Yan Li, along with their graduate students worked on social-driven educational IT projects for their studies. A mutual friend invited Manoj to meet her mom, Dr. Debra Stoner. Over dinner…Manoj and Deb formed a friendship based on mutual respect and their passions to bring education to those with limited access…CMES was born and in 2018 TWB incorporated as a 501c3 nonprofit corporation. We are committed for the long haul.

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.

 

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.”

 

 

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