Past teaching sessions and blog postsA couple of weeks back Dr Hamed Akhlagi, Advanced Trainee in EM, presented a talk on local anaesthetics with a focus on pharmacology and toxicology. Click here for the pdf of the powerpoint presentation.
Chest pain and the Heart Foundation Risk Stratification Guidelines in the real world
Anne-Maree Kelly from Western Health in Melbourne has examined over 700 patients with potentially cardiac chest pain in this paperpublished in the June issue of Emergency Medicine Australasia. Although the author's main conclusion appears to be that the NHF guidelines are somewhat of a failure in the real world, I think the study goes a long way to clear a lot of the fog around the issue of risk stratifying a chest pain patient.
Click read more to read my take on this article and on the business of ED chest pain assessment.
TCA and Quetiapine Tox
This week Chandima Panditharathna gave us a presentation on TCA overdose and touched on Questiapine also. It was a great talk but he was up against stiff competition from LITFL and for the sake of time I am going to just link to this fantastic post from them rather than summarising Chandima's talk. Honestly, if you read this post you neen't bother opening a textbook on the topic.
The only thing I can add is to stress that this is one situation where you should have a very low threshold for taking control of the situation early with sedation and intubation. It is a lot easier to administer Bicarb to a patient who is ironed out and ventilated than one who is fitting on the floor, or worse, one who is fitting below a pile of security guards. Remember that these patients frequently oscillate between periods of deep sedation and periods of agitated delirium in which they are seeing frightening things and are very excitable. This is a really unhelpful thing in someone who is heading towards malignant tachyarrthythmias and metabolic acidosis.
And remember also that like all tox cases, cardiac arrest is bad but can have excellent outcomes despite very prolonged CPR. I am not overly positive about the whole CPR thing in general but in the case of a toxicological cardiac arrest, the heart is otherwise healthy and the insult is completely reversible; this is one of the few situations where I would argue for truly prolonged resuscitation while oxygenation, fluid status and pH are all optimised. When all else fails you might even like to try intralipid.
For Quetiapine, see my entry from a few weeks ago.
EP workload. 100 tasks per hour
A paper by Rongsheng Kee and Johnathon Knott at the Royal Melbourne Hospital in the June issue of Emergency Medicine Australasia (EMA (2012) 24, 294-302) has described the workload of an Australian Emergency Physician. Table 1 is worth showing your partner so they can understand why you are less than talkative when they ring you at work. In case you don't have access, the gist is this.
As a duty consultant (in charge role) in every hour of the shift you will do the following:
Have 13 conversations with other doctors and the same with nurses, make or take 4 phone calls, talk to a patient's family and have around 6 conversations with other staff including police, ambos, clerical staff and students;
Walk 19 times between the different spots that you work in;
Review 5 patients, look at 6 files, use the EDIS system 10 times, use path and xray computer systems a couple of times each, look up some sort of medical reference perhaps once and make 6 medical record entries;
You will also occasionally write a sick note or prescription or discharge letter;
Once every few hours you will snack while working, and you'll have a drink on the floor about once an hour (scotch?); you will go to the bathroom once every 10 hours, go for a meal once in 10 hours and on one other occasion in that time-frame you will sneak away for an "unspecified" purpose (quick dose of ECT from the broken defib machine in the storeroom?);
It is not all bad news though. You will spend 24 seconds an hour on average in "quiet contemplation". I am comforted by that.
Everyone is blogging on this topic lately so I feel compelled to do so to. The trouble is, I am not sure yet if I am convinced by it. Either TXA is the best thing since mouldy bread or it's all just too good to be true. For anyone who came down in the last shower, CRASH 2looked at TXA in trauma patients in around 20,000 patients across 274 hospitals and 40 countries and found a significant improvement in all cause mortality. Surely that is enough said. Cheap drug, huge study, meaningful outcome, statistical significance. What could people possibly find to complain about? Well read on for a closer look, along with some primary exam stuff (because you can bet it is coming as a pharmacology viva question in the next year or two).