Going back to school.

While most of the #FOAMed world descended on the Gold Coast for #SMACCgold I was off to school with Ms 5. Going back to school was an interesting experience and reinforced the models used for teaching. As training CC doctors are pretty similar to five-year olds (see: attention spans.) I think many of them are directly applicable to our departmental training/teaching.

school 1st day

The first thing that you notice when you enter the class is the structure. Both in terms of location and routine. The day starts with mat-time where the days activities are discussed. After this follows news when those with something interesting to say have a turn to do so. Then a short break and some physical activity to burn off some energy. The day continues in this structured manner, with group activities alternating with independent work and regular breaks.

If a child does something that is considered bad behaviour they are not immediately punished. Often the first comment is distraction or a reminder to think about their actions. If they persist they are  moved from any distractions around them. Behaviour is defined by good and bad choices/decisions. Children are responsible for their own decisions but it’s also made acknowledged that the actions of others can impact this.

Role modelling is used to allow the smooth transition of children into the class room. You often hear “If you are not sure what to do look to one of the older children and follow their example” This extends to the playground. Older children are empowered to problem solve on the playground and not involve teachers unless they feel it is required.

Sessions in the classroom are explained in simple terms. Children are explained why they are doing activities as well as the practicalities. If unsure they are encouraged to ask questions of the teacher or their peers.


These concepts seem very simple and straightforward we sometimes struggle with them in hospital departments. How often do we hear  “do as I say not as I do…”   Whilst Shame based teaching is less common than previously, people are still singled out for attention without the context of the actions being taken into account. Another important factor is teaching they reasons for procedures or investigations rather than discussing the technique. This is even more important in heavily protocol driven areas.

After spending time in a class full of 5 year olds I will be going back to basics when it comes to departmental teaching.

Well done Crusaders!

Good to see the Crusaders medical team giving their player time to properly recover from concussion. Sadly some conversations about “rugby becoming soft” ect. Hopefully this culture can be changed. 

Keep your eyes peeled for the LITFL team current series on concussions and sports medicine.

See link: http://www.stuff.co.nz/sport/rugby/super-rugby/10020709/Kieran-Read-concussion-issues-not-cumulative




“Dad’s acting like a goldfish.”

55 year old man presents to ED in the presence of his son after becoming confused at the supermarket whilst doing his morning shopping.

No memory of why he was shopping, no memory of being in the supermarket or how he arrived there.

shopping trolley

Unable to remember drive to the hospital, unable to recall names of team.

repeated attempts to orientate to time and place. “whats going on bro?”

no other change in cognition. preservation of longer term memory.

denies drug use, no History of epilepsy, migraines, head injury.

 Normal neurological exam.

Throughout the time in the department the patient would catch the eye of staff who they knew before the episode wave and say “bro, whats going on?”

Bloods showed no abnormalities.

This constellation of symptoms is consistent with a diagnosis of:


 Transient global amnesia.

Diagnosis of exclusion.


Rapid lost of antegrade memory.

Repeated attempts to orientate themselves. often with a repetitive manner.

No change in level of consciousness.

lasting less than 24 hours.

Clinicians report perseveration as the predominant feature. Many can remember the specific mannerism of the TGA patients they have seen.

Rare condition: incidence in those over the age of 50 being: 20-30/100,000 per year

The cause of TGA is unknown but a number of hypotheses exist with migraines, epilepsy being initially linked but then more recently discounted. A vascular hypothesis is another disputed possible cause. With this number of possible causes being postulated it’s pretty clear we are unsure of the cause. This is likely due to TGA being a syndrome with multiple causes leading to hippocampal dysfunction.

The most comforting feature of TGA is that patients with “pure” TGA eg: only memory impairment which resolves they have a normal mortality and morbidity and a low chance of further events.


Patient was admitted to the ward for observation, symptoms improved with return of normal memory within 8 hours at which time he stopped waving. No memory of events of the day.

 Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600033/


Emergency and stroke physician combined consensus statement on thrombolysis for acute stroke

The latest NZMJ contained a consensus statement from the NZ faculty of ACEM which differs slightly from the ACEM statement. It is longer than the ACEM statement and fills out some of the brief statements. As with many of these documents many of the statements are fairly obvious.

Small difference is noted in the section regarding the informed consent for thrombolysis. Suggesting that it should be discussed by someone with sound knowledge of the benefits and harms. This doesn’t mention or require patients are informed of the disagreement amongst medical professionals of the risks and benefits of the intervention.” A minor but possibly significant difference.   

Another interesting statement is around the timing of thrombolysis with the group unable to come to a consensus around the utility of thrombolysis in the 3-4.5 hour group.

So here is their statement:

Consensus Statement:

  • Stroke thrombolysis with intravenous alteplase is applicable only to a minority of stroke patients and should be seen as a treatment option indicated in carefully selected stroke patients.
  • Patients should be selected in accordance with agreed protocols with explicit inclusion and exclusion criteria. These protocols should be aligned with the published literature and established collaboratively between emergency physicians, neurologists, stroke physicians, and other relevant stakeholders. Treatment outside of agreed criteria might increase the risk of adverse outcomes.
  • The strongest evidence for benefit of stroke thrombolysis is for patients treated within 3 hours of stroke onset. Emergency physicians, neurologists, and stroke physicians should work collaboratively to minimise treatment delays.
  • This group was unable to reach a consensus about the utility of stroke thrombolysis between 3–4.5 hours of symptom onset.
  • Inpatient stroke team pre-notification of a potential thrombolysis patient’s arrival is encouraged to facilitate rapid patient assessment and to assist with potential resource constraints in emergency departments.
  • Appropriate infrastructure should be present including timely access to neuro-imaging (CT scanning) and timely interpretation of these scans prior to thrombolysis by consultant radiologists, neurologists, or stroke physicians/delegated radiology registrars with appropriate expertise and training.
  • Informed consent for thrombolysis should be discussed and obtained by a medical specialist or delegated registrar with appropriate expertise and training in stroke assessment/management and with a sound knowledge of the benefits and harms of stroke thrombolysis.
  • There should be appropriate care and documentation of progress after thrombolysis including recording of vital signs and neurological observations according to agreed protocols.
  • Patients should be expeditiously transferred to a designated intensive monitoring ward area or Stroke Unit (ideally immediately following neuro-imaging prior to or immediately after administration of thrombolysis).
  • Services who provide thrombolysis should audit their service regularly to monitor safety and measure outcomes. Audit results should be reported routinely to local clinicians and regional stroke networks. Ideally a national database should be established to audit all stroke patients, including individuals treated with thrombolysis, to measure outcomes, with the results made available to all clinicians involved in the care of stroke patients.
  • The ongoing appropriate use of thrombolysis in stroke should be reconsidered as the results of audits, or further research, become available.

 Ref: NZ faculty statement:  http://journal.nzma.org.nz/journal/127-1392/6096/

 ACEM statement: https://www.acem.org.au/getattachment/1636cfd5-3829-4fc6-9eb2-91742f3d250b/Statement-on-Intravenous-Thrombolysis-for-Ischaemi.aspx

FOAMed question of the day 63 #FOAMedQOTD

What is the LD50 for caffeine?

How many standard coffees does this equate to?