Update in MindMap section

Hi, a new MindMap was made quite quickly this time. Since I'm going to make a new topic about asthma, I'm going to start the opening topic first: Basic lung function under BASIC category.

Click here to get to the MindMap section

Update in Event section

A new emergency medicine event will be held in Singapore. Sign up for early bird now!

Click here to go to Event section.

Update in MindMap Section

I'm really sorry for the long delay. I have to put up with lots of things since my M.D. graduation. I'm still in Indonesia, however I'm now on duty in RSUD Kanujoso Djatiwibowo for my internship program.

Enough for the chit-chat...

Well, I just updated the MindMap section for now. The new topic is about pre-eclampsia. I hope this will be helpful and please don't hesitate to give any supportive critiques for me to improve in the future. Thanks

Click here to re-direct to mindmap section

Update in MindMap Section

Reading too many text at a time may take your time A LOT. Let me just make it simpler for you by having you read in a form of mind map. I'll put a guideline if I think it would be necessary to do so.

The mind maps were self-made. Most of the source was taken from uptodate.com

These are some of the beginnings. I promise you that they will pile up in no time...

List of mind-maps available: - click here to access the mindmap section

1. Pediatric Febrile seizure
2. Pediatric Shock (Basic)
3. Pediatric Shock (Initial evaluation)

Here is one of them: (Pediatric Febrile Seizure)

Something sweet for the wound (#SurvivalGuide)

When you are in a secluded area, where access to medical resources is not possible, you may want to use some alternatives. These alternatives may not be included in any internationally approved guidelines, but good enough to save lives...

#SurvivalGuide 01 

- Something sweet for your wound -

It was 8 PM, you were walking down the forest with your friends, going toward the camp area. When suddenly a friend of yours slipped down two meters below. Luckily, no major trauma happened to her. She was conscious and cried for help; able to stand up an walked by herself. Though, there was blood gushing out from her right hand.

picture was taken from: http://www.todaysplanet.com/pg/beta/lizardlover/pic/vikki_big_bite_wound.jpg (Google picture)

The wound was covered by dirt and the base was hard to identify. Judging the situation, you decided to wash the wound with the drinking water you brought while assessing the function of the distal part, the capillary refill time (CRT), and the bleeding itself. The function was well and the CRT was below two seconds. The bleeding was still ongoing and you decided to rip some cloths to tie up the wound and put pressure on it. You and your friends rushed to the camp area for further assessment of the wound.

After further examinations and more washing with flowing water, three separated open wounds were identified. All of them had clear defined edges and the base of all three wounds were muscles. The bleeding had stopped gushing out, but the next thing to do is to disinfect the wounds and suture them. And none could be done because you had no tools to disinfect nor to suture. You decided to take her to the nearest hospital for further treatment; though, the nearest one would need 12 hours to reach by car. To drive a car in the middle of the night would be risky, so you had no choice but to postpone until morning. But....you worried the risk of infection since they were contaminated, but no povidone iodine or chlorhexidine could be found around the camp. You went to the kitchen and found some cooking ingredients: cooking oil, sugar, salt, honey, milk, and soy sauce. You brought the honey jar out and took a spoonful of it. You had your friend consent to put the honey over the wound and cover the wound up again using the cloth. 

The next day, she was brought to the hospital and had her wound stitched. She was well with no complication of infection.

HONEY?!! You said you use honey to cover the wound?

Yes...I'm all aware about what I wrote, especially about using honey to cover up the wound. Of course you would think what's the deal of using honey on the wound. 

-Honey as antimicrobial-

Besides of its function as beverages, honey had been regarded since long as one of the most efficacious natural resources. Honey has been studied (by Molan PC) in a variety of injury cases and has proven efficacious in promoting wound healing compared to standard treatment some of the examples:

1. Degree burns both mild to severe in adults and children with a faster recovery time compared to using silver sulfadiazine.
2. Wound infection after abdominal surgery with a recovery time much shorter than that of povidone iodine.
3. Decubitus ulcer healing with better proportions within 10 days compared with the use of saline soaked gauze.

Mechanisms of wound healing by honey mainly lies in the effects of antimicrobial, the main reason is because infection is a major cause of complications in the wound. However, the use of honey in wound healing providing additional effect, namely: eliminate the odor in the wound, the wounds debridation effect, and stimulates angiogenesis and growth of fibroblasts that can accelerate wound healing and minimize skin graft omissions or debridement. (by Molan PC - another study from above)

Focusing on its antimicrobial effect, honey has a variety of mechanisms that underlie this mechanism, namely: (Studied by Eddy JJ and Molan PC - more different study from him)

• Hyperosmolar state: hyperosmolar nature of honey can provide benefits in wound healing. With a water content of less than 20%, honey can prevent the occurrence of edema in the wound and cause dehydration in bacteria.
• pH: with a pH ranging from 3.5-5, this might added the nature of honey's bactericidal effect
• Hydrogen peroxide: hydrogen peroxide is a compound of honey which has antimicrobial properties. The content of peroxide in honey is quite unique, because it is activated by the dilution process. The higher the dilution, the higher the hydrogen peroxide content of the honey. It is another advantage of using honey on wounds, because the humidity may maintained by absorbing the water from the wound surrounding and at the same time diluting the honey. It has been observed that the hydrogen peroxide contained in honey may work more effectively because it is produced continuously by glucose oxidase; therefore, hydrogen peroxide will always be available with stable level on the wounds to some extent of time.

That's all for the first #SurvivalGuide edition. Well, you might want to try using honey instead of povidone iodine the next time you come across any wound cases.

Free UpToDate.com? - an accessible and accurate clinical answer for everyone -

Just as the title says, there is a free uptodate.com content in the internet. So, what is UpToDate.com? UpToDate.com is an internet based literature search, a peer-reviewed one, similar to medscape.com. The purpose is to bring a more accessible clinical answer to physician. Therefore, when we (clinicians) are facing the patient on an examination room, or even at the bedside, and having difficulties answering some questions regarding patients' condition, instead of reading thick books in front of them, we may look for answers at the net using smartphones.

Well....even though UpToDate.com is more accessible, the subscription cost may not be that feasible...

Therefore, there is freeuptodate.com that is accessible for anyone and anywhere. It is free and have the same content with uptodate.com. Though the version of articles may be older (last update date will be older) than in uptodate.com, most of the articles are usually have the exact same content. 

One thing you need to remember is that you need to login (at the top right corner) first when you want to read the whole content in freeuptodate.com. You will need to subscribe, but once again, it's free.

Let's get back to basic! - AMPLE

For every emergency situation, besides stabilizing the patient and asking for help, history taking is one of the most important thing to do. Basically, there are 4 things, arranged to be a mnemonic, to be asked to the patients or to the family:

AMPLE

A - Allergies

History of patient's allergy mostly determine the possibility of the cause and the option of treatments. Allergies may include drug allergies, food allergies, and possibly the environmental cause. The information about how long and how often the symptoms surfaced might not be really important.

M - Medication

Knowing what kind of drugs the patient take may have shorten the time to determine the disease of the patients and whether taking the drugs may cause present symptoms or not taking it might trigger the symptoms. 

The knowledge of the usual drugs the patient take may give us precaution on how to treat the patient especially the one with altered mental status - unable to give adequate information. For example, when patient taking a blood thinner (warfarin, etc), we may need to be more careful handling the blood taking. Knowing the patient take anti-depression drug may also give us insight on how to approach the patient and the possibility of drug overdose or toxicity (tricyclic antidepressants (TCA) toxicity).

P - Past Medical History

Past illness event might have a sequel for the present symptom. Knowing brief and important history of patient's past medical history may either rule in or rule out differential diagnosis. For example, a past medical history of deep vein thrombosis in a dyspnea patient will increase the suspicion towards pulmonary embolism.

L - Last meal

Last meal or oral intake may take significant role, in case the patient need some procedure to be done. Let's say the patient is needing a tube (endotracheal tube). While doing an intubation, rapid sequence induction (RSI) with sellick maneuver (cricoid pressure) may be done, if the patient had full-stomach, to prevent aspiration. Although, practicing sellick maneuver may still be a debate on its efficacy in protecting the airway from aspiration.

E - Event

Knowing what happened or how did it happen is as important as the other component of AMPLE, in fact, it may summarize things up from scattered information collected in A-M-P-L to be matched to the story of the patient, especially from the last period of his/her healthy condition.

Basic Life Support with no kissing scene? Where's the fun?!?

When we watch some action movies, we tend to see CPR a.k.a cardiac pulmonary resuscitation with the component of chest compressions and the heroic kissing scenes. Well....not exactly kissing, blowing air to be frank, giving the artificial breathing.

Mouth-to-mouth artificial breathing has been a component of Basic Life Support (BLS) sequence for ages. Though some people might grossed out to do so for a very reasonable reason: exchanging bodily fluids with unknown person which might lead to transmission of infectious disease. Well, since it is a guideline, the BLS providers are encouraged to do so. But, how about the evidence, does giving mouth-to-mouth artificial breathing give more benefit?

Removing mouth-to-mouth artificial breathing is rather a new concept which come from several reasons regarding the downside of giving artificial breathing, which are:

1. Transmissible disease between the patient and the provider
2. An unnecessary distraction (especially for the untrained BLS provider) for the most vital component of CPR: chest compression 

Moreover, the part of giving the patient artificial breathing may be replaced by the automatous breathing effect from the chest compression. Giving a chest compression might give secondary effect of pushing the air out and pulling it in, which supposedly give quite sufficient oxygen to the patient (compared to the breathe-out air from the patient which also contains more CO2).

Those are mainly the talk about the theory and stuffs, but how's the survival rate reported in the study? This is an interesting paper where the evidence come to play: Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest, comparing the survival rate in 1-day and 30-days between the use of compression-only CPR and the standard CPR. 

"The result showed a 30-day survival rate of 8.7% in the group receiving compression-only CPR and 7.0% in the group receiving standard CPR, while 24.0% of the patients receiving compression-only CPR survived for 1 day, as did 20.9% of those receiving standard CPR. There were no significant differences between the two groups with respect to the other secondary end points."

Well, we might see a little difference in survival rate, quite visible in compression-only CPR result for both 1-day and 30-days survival rate, though it was considered as no significant differences. Meaning? mouth-to-mouth artificial breathing supposedly will not give better result, considering the "extra miles" we have to go through doing it, than compression-only CPR.

As for now, compression-only CPR hasn't been approved as a guideline, though I have a standpoint of  doing so when doing BLS for outpatient setting.

Kudos to dr. Rahul Goswami for introducing me to this topic. His blog, emergence phenomena, can be accessed here: singem.blogspot.com

"Myocardial infarct? Naah...just send her home!!"

That sentence may be heard a lot in our workplace. A chest pain may be interpreted as an angina or just a muscle pain. Indeed the muscle is in pain, but to determine "which muscle?" may be the most difficult choice we've ever made. Either we send a patient home because of the nontypical chest pain leading to costochondritis, or we have to keep the patient in because we suspect of an angina.

Well, we learned from med school that we HAVE TO suspect a person for having an angina by several typical criteria:
1. Dull chest pain (heaviness or pressure on the chest), cannot be exactly pointed by the patient
2. Pain radiating to left arm or shoulder
3. Pain radiating to the jaw or to the back

However, we tend to exclude the possibility of someone having angina pectoris if they don't have any of the symptoms mentioned above. How wrong could this be??
Well, based on a review by Swap and Nagurney (2005), some symptoms were accounted and calculated to show the likelihood ratio of having acute myocardial Infarction:

1. Pain radiating to the right arm or shoulder (LR, 4.7)
2. Pain radiating to both arms or shoulders (LR, 4.1)
3. Association between pain and exertion (LR, 2.4)
4. Pain radiating to the left arm (LR, 2.3)
5. Diaphoresis (LR, 2.0)
6. Pain described as worse than previous angina or similar to previous MI (LR, 1.8)
7. Pain described as pressure was not very predictive of ACS (LR, 1.3)

I believe these facts might just slap your face. Well, believe it or not, you just have to prove it for yourself in the ER. Just remember what A/Prof. Amal Mattu said, there is no patient with chest pain can be considered as "no risk" for MI.

A reminder for all of us

A simple and nice 4 minutes to look at. You wouldn't waste your time watching it:

Your ED will more likely to have a higher mortality rate if you don't have this tool....

I'm not really sure that you can come up with something by looking at the title, but if I say a diagnostic tool that is repeatable, no radiation, and operator dependent, you will surely know what kind of tools what I had in mind...Good, man! it's the ultrasound..

I believe ultrasound is not a strange things anymore considering its wide use among doctors, even common people who are not doctors would know about the ultrasound. But, its use in the emergency department (ED) hasn't been widely enforced and I believe every ED doctors will eventually have to be able use it in the future. But, why is that? Ever heard about RUSH and FAST? Well, I'll let the professional do the work to explain it to you guys...

Rapid Ultrasound for Shock and Hypertension (RUSH):

Focussed Assessment Sonography in Trauma (FAST);

Blood taking hasn't been this easy!!

A practice of blood taking in Emergency Department is an usual sight. As the patient placed on the bed,  we usually take blood while setting the "plug" (IV line). Some may be done easily, since the veins are visible and were easily punctured, but then, some patients may suffer more because of the failure of puncturing. 

This was seen and been taken care of:

ISRN Emergency Medicine
Volume 2012 (2012), Article ID 508649, 6 pages
doi:10.5402/2012/508649
Research Article
Comparison of Full Blood Count Parameters Using Capillary and Venous Samples in Patients Presenting to the Emergency DepartmentR. Ponampalam,1 Stephanie Man Chung Fook Chong,2 and Sau Chew Tan1
1Department of Emergency Medicine, Singapore General Hospital, Outram Road, 169608, Singapore
2Department of Clinical Research, Singapore General Hospital, Outram Road, 169608, Singapore
Received 29 May 2012; Accepted 10 July 2012
Academic Editors: A. Banerjee, C. C. Chang, and A. Pazin-Filho
Copyright © 2012 R. Ponampalam et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Full blood count (FBC) analysis is a common investigation done in the emergency department (ED). The aim of this study was to determine the accuracy of bedside FBC analysis using capillary blood samples from a finger stab at point of care (POC) compared to a conventional venous blood sample analysis. A total of 314 consecutive patients presenting to the ED were recruited. After consenting, a sample of the patient’s venous (V) blood was obtained via venepuncture and sent to the haematology laboratory for analysis as standard practice. This was followed immediately by collection of a capillary (C) blood sample from a finger stab which was analysed at site using an automated FBC analyser at POC. Agreement between the paired samples for blood parameters including the total white cell count, hemoglobin, and platelet count was assessed by the statistical method of Bland and Altman using V sample as the gold standard. The results showed a statistically significant deviation between capillary and venous samples only for platelet counts (𝑃 < 0 . 0 0 1) and haemoglobin (𝑃 < 0 . 0 0 1). However, the magnitudes of this difference 7.3 × 109/L and 0.5 g/dL respectively, were not clinically significant. The study suggest that the analysis of capillary samples for FBC parameters is a reliable and acceptable alternative to conventional methods with the benefits of being a rapid, convenient, and minimally invasive technique.

The full article may be read here:

ISRN Emergency Medicine Journal

"Sorry mam, your husband is dead..."

As we work in emergency room, patient's condition may deteriorate anytime depend on the severity of the disease, and breaking the bad news to the family member become inevitable. We tend to be too busy saving lives, sometimes we forget to inform the family about the condition of the patient. Giving information to the patient or patient's family is one of the most important part to keep a stable doctor-patient (especially patient's family) relationship. A timely-wise report to the patient's family may even prepare the family to face the worst possible outcome.

This video might give us enlightening on how to make it happen: