The Unofficial Bone Shop House Surgeons Survival Guide

April 12, 2013 by Leave a Comment

During my time in Christchurch I worked in the bone shop,

There was a book/PDF that was distributed which helped many of us early on and serves as a great refresher.  In the interests of #FOAMed I thought I should share a couple of links.

Before doing this I checked with Chris Cresswell ( @emtutor ) who wrote the original! which has since been edited. Its full of practical advice and worth a read. The word doc is good to have on your smart device of choice. As with all of these sorta things, doesn’t replace your local advice/protocols, If it seems odd check something else!

I decided I should put the first page up so you can get the flavour and practical nature of it.

viva la #FOAMed

  • The Unofficial Bone Shop House Surgeons Survival Guide
  • Welcome to The Bone Shop
  • Don’t try and read the whole of this guide.  Read the introductory paragraphs, then before you see each patient look at the X-rays, read any previous notes, referral, consultant film reading, look the injury up in this guide, talk to the nurse, look up McCrae and decide what you’re going to do before the patient comes in.
  • Everyone expects you to know nothing.  The nurses know everything and will give you lots of help.
  •  For the first few weeks you will feel you are superfluous and are slowing things down.

 

  • It’s not your fault the waiting room is full: the head of department acknowledges there is a staff shortage and inadequate orientation.
  • What is acceptable angulation/displacement? A lot of the time we don’t know.  If you can get anyone to define “acceptable” for various injuries please add it to this guideline

 

  • Consider non accidental injuries.  Have a low threshold for discussing with paeds reg.
  • Consider bone strengthening medication for post menopausal women and men over 65 with #s.  We can prescribe calcium (eg calcium carbonate 1.5g bd) and vitamin D (eg calciferol 1.25mg daily for 7 days then once a month).  They need to see their GP to obtain bisphosphonates (eg alendronate).
  • Analgesia/sedation:Bier’s blocks may be performed by an anaesthetic SHO (or above) and are available in “working hours” (d/w duty anaesthetist), or you can do them yourselves provided there are 2 of you – one to do block and manage the cuff – and the other to do the manipulation.  You need to have attended a teaching session on Bier’s block by Anaesthetists prior to being able to perform the blocks yourselves.We do not currently use ketamine/propofol/etomidate in Bone Shop.

 

  • One alternative is using haematoma blocks (including selected ankles that need manipulating), regional nerve blocks, IV fentanyl eg 100µg, IV midazolam eg 1mg (or 0.5mg in the elderly) and Entonox.
  • For kids consider using 2µg/kg intranasal fentanyl as analgesia.
  • Consider using the 70% nitrous mixer from ED if you’ve been trained to use it. Remember to turn it off.

 

Links:

Text copy on EM tutorials:

http://www.emergency-medicine-tutorials.org/Home/surgical/orthopaedics-and-hands/ed-orthopaedic-fracture-clinic-guidelines

Dropbox for word download.

https://www.dropbox.com/s/t0igcoih2jbhjgz/The%20Unofficial%20Bone%20Shop%20House%20Surgeons%20Survival%20Guide.docx

 

 

#FOAMed

 

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Thoughts on Poker and Medicine

March 18, 2013 by 4 Comments

While listening to Simon Carley on risk at #SMACC2013 I had one of those thoughts.

Medicine is more like poker than a lottery.
March 12, 2013 10:38 AM via Twitter for AndroidReplyRetweetFavorite

First I hope any serious poker players can forgive my over simplifications of a wonderful game. I also hope everyone can forgive my extreme stretching of this metaphor.

 

So why is medicine like a poker game?
It’s about prediction and probabilities, sometimes we are accurate and can be quite sure of ourselves but sometimes we get caught out by a surprise card or unlikely diagnosis.

In emergency medicine we often concern ourselves with the dangerous diagnoses, most poker players consider these options and likelihood their opponent will draw them. If you have played against a person/disease many times you can be more confident that you will be able to  judge their strength or recognise their tells.

In both luck plays a role that both doctors and card players are uncomfortable with. Everyone will have a “bad beat” where you are confident that you have the correct response or reaction but something unlikely/rare happens and you lose. This leads to both groups having superstitions and sayings which are similar.

“You play the man not his cards” sounds a lot like “It matters more which patient has the disease than which disease the patient has”

Like poker, medicine can be played at a number of stakes. Is it a life and death situation or just trying to rid someone of a minor irritation.

Texas Holdem

Medicine is most like Texas holdem (heads up).
I’ll explain why with an explanation of how it’s played and the similarities.

Heads up poker is played against one other person. You have your own cards and there are a number of communal cards which you make your best hand from. In this way a poker hand reflects a medical consultation information is slowly revealed and you attempt to gauge your position and certainty.

The rounds are as follows:

Pocket cards:

File:Pair of Aces.jpg

Firstly you are given two cards, an initial impression. You know from a glance if this patient is sick or not. Your system 1 is firing on all cylinders. You may get an instant diagnosis from the end of the bed, ?pocket Aces.

But you also know when you don’t have an idea. You know it will be hard or perhaps you just don’t want to play this hand.

Everyone makes their bets, some times this is easy. The patient is dry start some fluids, pain relief/Raise. Other times you don’t want to initiate much treatment until you have more information/Check.
In medicine you can’t really fold. unless you take the next chart (don’t be this person).

 The flop:

Three cards are turned over. This equates well with the history, it’s where the money is. Based on what you know about the patient and you impression most times you can have a very good idea about how you are placed. But there is some difficulty. Many diseases are difficult to tease out, are you being bluffed by your opponent. Previous experience with the opponent/disease can help you here. Are they likely to play passively or do they often show their strength?

The Turn:

This is the physical exam. (might be giving too much credit here)

This adds to what has come before. The reaction to this, tells/focal signs often increase your confidence in your diagnosis. But again it can leave you feeling unsure. But often it makes minimal difference, your impression can remain unchanged based on presence or absence of some signs. This is also often when you take a little time to think of any other possibilities you may have forgotten, a few extra questions whilst examining.

 The River:

 The investigations. Everything is back, all the information you are going to get is there.

This confirms or refutes your previous thoughts. You often know where you stand are you “the nuts” ?

But everything can change and swing based on one investigation/the final card. Is the bloody D-dimer positive? 

Then the final rounds of betting, are you all in for one diagnosis or are you still unsure of yourself? Often you know your badly placed (Pt is sick) but you can’t be certain of why.

 Finally the hands are revealed; in medicine like in poker you may never find out if you were right. Your opponent may never reveal their cards.

The best you can hope for is to learn from your mistakes, minimise your losses and be ready to play again.

But remember, in the end the house always wins.

 

 

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Leptospirosis in Aotearoa

January 15, 2013 by 4 Comments

 I recently had a patient a 42 yo dairy farmer who had not been right for a week. Flu like symptoms, headache and lethargy.

He was a “good keen man” a deer hunter who brought home steaks with respectable frequency. His partner had bullied him to the clinic. He had been unwell enough to take to bed which his partner reported was most unusual. Usually fit and well with ono PmHx. Being summer and his symptoms he earned a leptospirosis serology test.

Which came back as positive with a significant titre.

Treatment for  symptomatic cases here is oral doxycycline and follow up to see if symptoms resolve.

#FOAMed and Leptospirosis

After looking around I found the Excellent talk from Dr Lane (ICU Queensland) http://www.intensivecarenetwork.com/index.php/icn-activities/icn-podcasts/393-39-lane-on-tropical-microbiology But his experience didnt fit with mine. Are kiwis just tougher than those weak australian soldiers he sees? or is there some other factors effecting the cases we see?

Also the Adventure doc blog had an article: http://adventuredoc.net/2008/12/29/leptospirosis/

Firstly what the hell is leptospirosis?

To quote professor wikipedia Leptospirosis (also known as Weil’s syndrome, canicola fever, canefield fever, nanukayami fever, 7-day fever, Rat Catcher’s Yellows, Fort Bragg fever, black jaundice, and Pretibial fever) is caused by infection with bacteria of the genus Leptospira

Have I heard of that?

Leptospirosis was in the news in 2010 when british olympic rower Andy Holmes passed away after contracting the disease.

How does it present?

“Lepto” can present like just about anything from a mild flu like illness to a severely sick patient with hepato-renal syndrome and meningitis.

Natural history of leptospirosis

Usually patients will have the initial phase with flu like symptoms For many this is all the patient will experience but for some this is resolves and they then have a second phase of illness. This is more severe and may include hepatic failure (Weil’s disease) and renal involvement.

So how common is it?

Worldwide it is one of if not the most common zoonotic disease.

Leptospirosis is a notifiable disease in NZ so we have good records of when lab tests come up positive.

New Zealand has between 80-140 confirmed cases a year, this is about three quarters of the positive lab serology results. (more on this later)

Making leptospirosis not common but not rare. So it falls into that BS category of “Maintain a high index of suspicion” Now im pretty sure there isnt a suspicion index but you will see it from time to time. (if you look)

Which leads to the question of who gets it? meatworksdeer

 

 

 

 

 

 

 

 

 

 

 

 

Meat workers, esp those who “pull kidneys” or work the offal line. Deer hunters and farm workers are other high risk groups.

Risk in NZ

Over the years there has been a number of vaccination campaigns in cattle, pigs and now they are trialing deer vaccines to reduce the carriage of leptospira in herds. Despite this amongst herds some animals remain positive/carriers. Around 70% of beef herds, 40% of sheep and 80% of deer herds have leptospira. This is highest amongst farms which graze both cattle and deer.

These figures lead to an estimated exposure of 8-25 leptospirosis carrying carcases per day for a meatworker.

Why is it not everywhere? Are we missing cases?

Waikato epidemiologists feel it is likely we have significant underreporting. The serological evidence that many people are infected and clear the leptospira without significant illness. Currently the ELISA has a low sensitivity and it is felt that serology is better for clinical diagnosis. The culture may take a number of weeks to become positive. To be eligible in NZ for Accident compensation corporation funding/payments you must have appropriate symptoms and a rise in your serology titer of 4 fold. It seems a safe bet that we are missing a number of cases.

Leptospirosis mortality:

In contrast to Dr Lanes Queensland experience deaths from leptospirosis are quite rare in New Zealand with one every few years.  New Zealand appears to have slightly different endemic strains of leptospira. Also the soldiers are likely exposed to rodent urine vs that of bovines. Rat urine is more commonly infected with the more virulent strains of leptospira. A final thought from me about deaths from Leptospirosis: As deaths are reduced by immunomodulation perhaps the soldiers who are often being exposed for the first time to these antigens vs the meat workers who have a chronic exposure simply do not have the same immune overreaction?

 So how did the patient do?

My patient improved over the following few days but took a couple of weeks to “come right” This was defined as  being able to spend a couple of days staking deer in rough terrain and delivering me some venison steaks!

vension steak

References:

Paul Lane, ICU (Queensland) http://www.intensivecarenetwork.com/index.php/icn-activities/icn-podcasts/393-39-lane-on-tropical-microbiology

A new dawn of leptospirosis in New Zealand“Turning prevalence to incidence”
C Heuer et al. http://epicentre.massey.ac.nz/acvsc/scwk_08/Heuer_050708.pdf

Professor Wikipedia et al. http://en.wikipedia.org/wiki/Leptospirosis

 

Filed Under: #FOAMed, Cases Tagged With: ,

A quick ECG from my mummy

October 15, 2012 by 3 Comments

Got sent this ECG by my Mum who is a kickass emergency nurse and midwife.

She saw a young man who came in after a syncopal episode.  Thoughts on the ECG?

Update October 17:

So had a few comments and thoughts on twitter and here people are pretty onto it with this one.

My thoughts:looking at the ECG,

Sinus rhythm rate of 60.

V1/V2 and maybe V3 have what i would agree look like Epislon waves. T waves are not inverted.

High voltage ECG but difficult to accertain in a skinny young male.

QTC is 390 but the QRS in V1-V3 is not widened.

So we have a young mane with syncope our concern is hypertrophic/arrthmogenic cardiac disease in this case ARVD (Arrhythmogenic right ventricular dysplasia)

First a bit more on ARVD,

ARVD is a genetic defect that causes fibro/fatty change in the myocardium. It predominantly effects the right ventricle.It has an incidence of  1/1000 with a male predominance, from 1/3 to 1/2 of cases are familial. For those working in Italy apparently it has a much higher incidence possibly as high as 40/1000. It is a major cause of cardiac death/sudden death in children and young adults.

The diagnosis is made Via ECG findings, Family history, ECHO +/- endomycardial biopsy

Diagnosis of ARVD: requires 2 major criteria and one minor.

Major Criteria

Minor Criteria

Touch more about Epsilon waves apparently can be caused by other diseases of the right ventricle, including right ventricular infarction, infiltration disease, and sarcoidosis which might also produce the pathological substrate required for production of epsilon waves.

Outcome of the case:

Patient was referred to the tertiary ED who happily took the patient. They were admitted under cardiology and patient had an ECHO which showed no concerning features! Bloods were all normal. Kept on telemetry and discharged home with follow-up. I am unsure if they are planning on going to Biopsy or not at this stage.

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A Flying Kiwi!

August 16, 2012 by Leave a Comment

I recently had my first helicopter transfer of a patient. Young pt in 20′s.

Presented at 2330 with hemetemesis and PR malena, initial Hb 105. Ur 9.3 Bp 105/80 PMHx of previous bleeds and duodenumitis on scope 3-4 months ago. admitted to the ward with IVF, omeprazole.

At 0300 the patient was up to commode and passed <1L of malena and “Flaked out”

BP 80/50 P 135. pale Hb 85

Transfused 2 units and Fluid resus with target BP 100 sys.

Taken to theatre in morning 0800, Scope found large clot in 2nd part of duodenum but no fresh bleeding.

Discussed with referral centre who felt was reasonable to transfer as unable to perform emoblisation if “rescue” required after clipping.

Pt holding BP 102/60 HR 100ish.

Pt was for Helicopter Transfer (fixed wing busy) and had blood running but was felt likely to require further en route.

In NZ paramedics cannot initiate further bags of blood if required (stupid system) so they required a doctor to take patient.

So it fell to me to go. I have done ATLS but no prehospital medicine courses but do like the PHARM podcasts and felt more or less comfortable with doing it.

So was happy with few things, A,B wise was stable at that time, had backup options but god would not have wanted to use them. C had good access as had two large bore cannulae placed. Collected 2 more units of blood as a good boy scout felt be prepared is a good way to be. Lots of fluids.

Its load into ambulance and then to the helicopter and loading up. Its a small place and doing anything is a bit fiddly. Safety brief from the pilot “dont walk into any rapidly spinning blades, it makes a big mess and I hate paperwork”

After the shuffle we were off!

Weather was pretty bad but the pilots here are guns and know all the passes ect, still felt nervous flying at 200ft over the ridges/saddles.

The Pilot put it well, “helicopter, mountains, beautiful. but I like them separately not together”

<—-Nasty weather shot

Patient had a good going fluid requirement and I was convinced he was still bleeding throughout the transfer. I was playing with pressure bags a bit as we dont use them much in hospital with rapid transfusers and pumps.

Over the course of the transfer, 80 minutes patient received 2 units of blood and 3 litres of saline. but was more tachy on arrival P 120 and BP 95/55 and taken straight to theatre where bleeding ulcer was clipped. Patient did not require embolisation but had further 2 units as arrival Hb was 78.

On review, I felt it went pretty well. I have a massive amount of respect for people who do this regularly. The pilots are really amazing, flying over mountain passes with low visibility was frankly scary. From a more medical point of view little stuff makes a big difference. Its an old rule of PHARM stuff but know your kit, playing with pressure bags ect was frustrating when it should have been simple. Helicopters are a very small you forget how often you move around to do procedures ect.

So to ask anyone whos reading, have you done transfers, lots? a few? do you remember your first?

 

And finally some scenery shots for you all:

 

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