Newborn Normal

Photo courtesy HandUp Congo.

What is normal and abnormal in a newborn? Stridor, periodic breathing, vomiting, eye discharge? Which of these merits investigation and treatment?

Using your thumb drive or CMES-Pi device take a listen or a quick read of the May 2020 EM:RAP podcast or pdf titled, Newborn Normal by Anand Swaminathan MD and Zach Drapkin MD.

 

 

Part of Great Ormond Street Hospital in London, United Kingdom, which was the first pediatric hospital in the English-speaking world. (Wikipedia)

Who Knew? Some of the oldest traces of pediatrics can be discovered in Ancient India where children’s doctors were called kumara bhrtya.[2] Sushruta Samhita an ayurvedic text, composed during the sixth century BC contains the text about pediatrics.[4] Another ayurvedic text from this period is Kashyapa Samhita.[5][6]

Culture Framework: Tight or Loose

COVID-19 tent at a Swedish hospital emergency entrance. (Wikimedia)

Shankar Vedamtam, NPR Hidden Brain host, interviewed Dr. Michele Gelfand, a psychologist at the University of Maryland about her framework of “tight” and “loose” cultures.

Tight cultures, she says, are more rules-oriented. Loose cultures are more permissive. “Countries like Japan, Singapore, Germany, and Austria tend to veer tight,” she says. “And countries like New Zealand, Brazil, the Netherlands, and Greece tended to veer loose. And of course, all countries have tight and loose elements.”
Her article “To Survive the Coronavirus, The United States Must Tighten Up”, published 3/15/2020 in the Boston Globe describes how the cultural norms of a culture directly impact the trajectory of the virus.

The empty Olympic stadium, Germany (Wikimedia).

How has your culture responded to coronavirus rules instituted to protect your country? Is it working?

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.

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