Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

Workshop for EMS Gathering

This is the post I created for the guys who attended the “Social Media and EMS” workshop at the Irish EMS Gathering in May 2013. Hopefully something from the 2.5 hrs stuck in your brains so that you’re not seeing all this as entirely new material.

Twitter

Firstly we got everyone to join Twitter. You can do this via the website or via an app on your computer or phone. For interest sake I use TweetDeck through Chrome on my computer and use Twittelator Pro on my iPhone.

I suggested that when you join twitter you should put a little of biographical information about yourself. People are more likely to interact with you if they know something about you. There are a lot of fake, spam Twitter accounts and having some info on someone helps people to trust you.

I suggest having a profile picture as well rather than the default, anonymous egg.

Twitter EGG

For example here’s mine:Andy Neill Twitter Profile

Follow People 

When you get started I suggest you follow a few key people to start with. Here’s 5 to get you started:

@sandnsurf

@precordialthump

@cliffreid

@broomedocs

@M_Lin

The more interact, post and reply to people, the better your twitter experience will be. We don’t bite honestly, we loved being asked questions on Twitter.

Follow Lists

You can also follow lists, either other peoples or your own that you create. This is a good way to ensure that you’re spending your time well on Twitter. If you make a list of people who consistently tweet high value info then you’ll not be bored by dross about people’s dinner…

Here’s a list I have of “medical tweeters

Follow Hashtags

Hashtags [words beginning with the '#' symbol] are good ways to join conversations together. My favourite hashtag is #FOAMed, this is a consistent conversation about FOAM resources. You can type #FOAMed into the twitter website or onto your twitter app to find it.

NB, on a mac the # symbol is produced by pressing the ‘option/alt’ key and ’3′ together.hash key

If you want more twitter basics then check out momthisishowtwitterworks.com

Podcasts

I think the key is to get your podcasts on your smartphone. That way wherever you are yo can listen to them. It’s much more important to have them on your phone your computer in that sense.

The basic ‘podcasts‘ app from apple on the iphone is a reasonable place to start.

podcast 1

Once downloaded, start the app and click the ‘store’ button.

podcast 2

 

 

Once you’re in the store, search for whatever it is you’re interested in.

podcast 3

 

Once you find a podcast you want to subscribe too, just click on the subscribe button. Every time a new podcast is released it should download automatically to your phone.

podcast 4

LITFL have a great list of podcasts and a searchable database too, if you need to find more.

Feed Reader

Most of the FOAM websites produce new material on a regular basis. To save you having to visit the site to check if new amterial has been released, you can use something called a feed reader that will collect all the new material from all your favourite websites in one place. I used to recommend Google Reader but it’s shutting down in July 2013 and I’m now suggesting feedly as a good alternative.

feedly

Once you’ve added feedly to your internet browser or downloaded the app to your phone or tablet then you can add the websites you’re interested by either clicking on the RSS symbol on the website

RSS

 

or copying and pasting the website URL into the search box

feedly search

The mobile app is kept in sync with your computer and is set out in a similar easy to use way.

If you’re looking for one place to look for all the best in FOAM then check out Kane Guthrie’s LITFL review.

Blogs

So say you’re keen to start putting out your own FOAM material, then starting a blog is a good way to start. Here’s the website we set up at the workshop in 15 minutes.

This is what the ‘dashboard’; the construction site of the website looks like.

wordpress

This is all free and easy to do via wordpress.

Google Plus

We only mentioned this briefly but I said I thought it was a brilliant platform for FOAMed but unfortunately under utilised. Its best features are probable communities [check out ECG+ and the EMCrit community] and the google hangouts. Here’s a nice example of google hangouts being used to stream a conference live.

 

Or here as a conversation between experts discussing some medical papers. Saves all the hassle (but not quite as much fun) of actually meeting up.

Screencasts

Due to technical issues we couldn’t quite pull this off live at the workshop but a screencast is typically a recording of what’s on your screen with a voice over. It’s a great way to share a lecture you’ve prepared with lots of other people. Once the video file is made you can upload it to YouTube, Vimeo or even better GMEP for other people to see.

Screenr.com let you record screencasts without having to download a separate app but I do a fair bit of this so I use one called screenflow.

As an example here’s a screencast of the talk I gave at the conference.

Lastly the app I used for displaying my iPhone screen was one called Reflector which is $12 but a really, really well put together app that lots of people recommended but I first found via Haney Mallemat and my brother the software developer.

UPDATE Michelle Lin has just published a nice piece here outlining some social media basics

EMS Gathering – Killarney, Ireland. May 15th-16th 2013

EMS Gathering

Just a little shout out to a conference I’m speaking at next week.

The Irish EMS gathering is a conference aimed at pre-hospital specialists being held in Co Kerry, way over there in the south west of Ireland. The program (see morning sessions, afternoon sessions and evening sessions) is a good mix of academic and leisure activities so it’s definitely worth checking out.

They were foolish enough to let me talk on social media and the auld Twitter malarkey which is a real honour for me. I’m speaking on Wednesday morning and hopefully running a workshop on the wednesday afternoon as an introduction/development session on how to use the old interwebs to learn and share effectively.

If anyone is going please stop by and say hello, it’d be lovely to meet you.

As far as I’m aware they’re still open to registrations and I’d highly encourage you to come along.

I’ll endeavour, as usual to do a screencast of my presentation for the rest of you all to enjoy/criticise/abuse…

 

Standing Test for Long-QT syndrome

This was all brand new to me. I was reviewing a syncope patient left over from the night shift before. The hand over was: recent change in anti-hypertensives, now feeling weak and dizzy about 1 week. Syncopal episode at dinner table last night.

She’d been in the department overnight, got some fluids, bloods and an ECG. The ECG was said to be normal.

I went and chatted to the patient and yes indeed it did sound all very like postural hypotension. I went back and looked at the ECG and did my usual syncope ECG review looking for the following:

  • Brugada
  • HOCM
  • WPW
  • intervals – QT and PR

And there it was – a nice big QTc of 550ms staring at me.

I still suspect that postural hypotension was the main cause of her symptoms but it would be a tad on the risky side to call it that in the context of a long QT. K+ and Mg++ were on the low side (3.5 and 0.6) so she got a bit of both and admitted for ECG monitoring.

The interesting bit came in the discussio with admitting doctor who was (for once) interested, enthusiastic and asked about the standing test for Long QT. This was all news to me but effcetively people with a long QT syndrome (LQTS) have an abnormal response in QTc with standing.

In healthy people on standing the heart rate goes up with corresponing shortening of the QT interval. Due to the fact that heart rate goes up more than the QT comes down, the QTc actually goes up slightly,

In LQTS the QTc often goes up substantially.

This paper addresses this concept and while it’s in now waty perfect (ie it examined it in people known to have LQTS which undermines its use as a diagnostic test in undiagnosed QT problems) it suggests that in healthy people an increase in QTc on standing of about 10-15ms is allowed but in LTQS is likely to be in the range of 90-100 ms.

Viskin, Sami, Pieter G Postema, Zahurul A Bhuiyan, Raphael Rosso, Jonathan M Kalman, Jitendra K Vohra, Milton E Guevara-Valdivia, et al. “The Response of the QT Interval to the Brief Tachycardia Provoked by Standing: a Bedside Test for Diagnosing Long QT Syndrome..” Journal of the American College of Cardiology 55, no. 18: 1955–1961. doi:10.1016/j.jacc.2009.12.015. PMID 20116193

 

METHODS

  • the normal response to standing after lying is an increase in HR. This would normally be accompanied by a shortedned QT. In LQTS this apparently isn’t the case
  • The intervention was standing and recording QT changes.
  • they did this on high risk LQTS (lots of features but no diagnosis as yet) and those who actually had it genetically documented. The controls were healthy relatives of those pts or volunteers (the vast majority)
  • took them off Beta blockers for a day then lay them flat 10 mins and stood them up for 5 mins with telemetry.
  • blinded investigator performed the measurement had a set part of the trace. Bazzett’s  formula was the main one used.
  • excluded the obviously normal and obviously prolonged

 

RESULTS

  • 68 LQTS; 82 controls
  • the baseline QTs were 380 v 450 – not diagnositcially different but borderline
  • the QT went down in all the normals but less than the RR interval therefore the QTc goes up slightly.
  • the QT of those with LQTS didn’t change at all. In some it went up. Or put another way the QTc of the control group went up 13ms while the LQTS patients the QTc went up 89ms

Not something I’m going to be doing every day, but it’s a fairly nice, bedside test that we can apply in the ED.

Anatomy for Emergency Medicine 027: Basic Anatomy of Abdomen and Pelvic Trauma

This is the second part of a recent lecture I gave to some first year med students to get across how important their anatomy is to understanding trauma.

First part lives here

You may have to click through to the GMEP site to see the full HD version

PDF of slides

Cranial Nerve Palsies -III, IV and VI

This isn’t so much an AFEM post but more of a brief review of a paper and a video.

Everyone finds neuroanatomy tough, you’re not alone. Most of it doesn’t really concern us in the ED that much. However we will have people attend or be referred with isolated III, IV and VI palsies.

If you understand the basics you can  know when to get worried and scan and admit and to relax and explain to the patient that this will likely improve with time.

First I suggest watching this video from the single best eye teaching source I’ve found [Chris Nickson found it for me of course :-) ]

I also found this paper [via the only neuro blog I read] which covers the anatomy but also some advice on when to image and when not to. This is my basic summary.

In general

  • a lot of isolated palsies can be observed as most are vasculopathic and will resolve
  • isolated palsies in young people should cause consideration for mass. Non-vasculopathic sixth palsies are relatively high risk here
  • the key point is identifying isolated. If they have headache or other signs then it’s not isolated
  • temporal arteritis can be involved in all of them, as can myasthenia but there should be other signs/symptoms

III

  • if motor only can usually be observed as most will be vasculopathic if the risk factors exist
  • if mixed motor and pupil should be imaged
  • if pupil only then think about compression

IV

  • even traumatic IVs don’t need imaging for ICH (though maybe for fracture)
  • head tilt is common along with pupils not at the same level
  • some are congenital that have decompensated
  • again the vasculopathic ones do quite well
  • sub-arach space rarely involved
  • isolated non-vasculopathic ones may (with caveats) be observed (unlike VI and III)

VI

  • traumatic VI needs a scan
  • vasculopathic can be observed
  • non-vasculopathic should get scanned (they quote a 25% malignancy rate which seems awful high)
  • they oddly don’t mention benign raised ICP as a cause

In the ED it’s not always as straightforward as this as the key is follow up. Depending on your access to neurology/ophthalmology will dictate how you manage them.