#FOAMed Question of the day: 1 #FOAMedQOTD

Which classic new years injury is shown?

Answer

GP CME South 2013 #GPCMEsouth

This week I shot down to Dunedin for the NZ medical associations CME conference.

top_banner2013

It was a great event and had a huge variety of talks and informal Q+A sessions.

See programme here:

http://www.gpcme.co.nz/south/programme.php

It was a little lonely on the twittersphere (#GPCMEsouth) but the teams from Canterbury health laboratories and New Zealand Doctor magazine keep me company.

The social media talks were well attended and in the plenary sessions others spoke about the need for doctors to have more information in the public realm. I did have the slight embarrassment of being called out at the #SoMe talk as a “serious tweep” and “blogger” (Thanks Barbara!)

Our wee kiwi GP conference managed to generate 224,403 Impressions! which was quite cool and It was really nice to get lots of messages from those who enjoyed the info flowing onto their timelines. Symplur here

Many of the presenters have been kind enough to let me write about their talks and include a few pearls in a longer format than 140 characters.

So over the next few weeks I should have a few interesting talks to cover and hope to share a few learning points and help solidify my thoughts as well.

The Unofficial Bone Shop House Surgeons Survival Guide

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

 

Thoughts on Poker and Medicine

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

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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.

 

 

Leptospirosis in Aotearoa

 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