There is no spoon?

Prof. Rinaldo Bellomo is extremely well published and speaks here at SMACC Berlin in a Matrix like talk on physiological belief.
Some great lines here and some well thought out arguments. Chiefly, "we make the measurable important but not the important measurable". Thanks to the SMACC team for making this available.

Webucation 5/5/18

Web wisdom this round comes from gurus in EBM, critical care, trauma and even some philosophers on the state of affairs in medical education/administration. Credit as always to the original content providers.
  • The trouble with mindfulness - one of the best articles I have read recently relating to error prevention and human behaviour. Well worth a read even if not in a "medical" mood.

Clinical you say?

Thanks to Journal Watch for this article:

Clinical Signs Accurately Identify Pneumonia, Study Suggests

by Jennifer Garcia
Four clinical variables — the presence of fever, elevated pulse rate, crackles on auscultation, and low oxygen saturation — can help identify patients with pneumonia in the primary care setting, according to new data.
"[T]he four variables identified by this analysis are easily measured clinical signs," write Michael Moore, BM BS, MRCP, FRCGP, from the University of Southampton, Aldermoor Health Centre, United Kingdom, and colleagues.
"If antibiotic prescribing was restricted to people who had one or more of these signs, it could substantially reduce antibiotic prescribing for this condition," the authors write in an article published online November 22 in the European Respiratory Journal.
For the prospective cohort study, the researchers evaluated 28,883 patients between 2009 and 2013 who presented to their primary care provider with symptoms of acute cough attributed to a lower respiratory tract infection
Among the 720 patients radiographed within the first week after their initial consultation, 16% (115/720) were diagnosed as having definite or probable pneumonia.
The researchers noted specific independent predictors of radiograph-confirmed pneumonia among this cohort, including temperature 37.8°C or higher (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.46 - 4.81), pulse rate 100/minute or higher (RR, 1.90; 95% CI, 1.12 - 3.24), crackles on auscultation (RR, 1.82; 95% CI, 1.12 - 2.97), and oxygen saturation below 95% (RR, 1.73; 95% CI, 0.98 - 3.06).
Overall, 86.1% (99/115) of patients with pneumonia exhibited at least one of these clinical signs. In contrast, other factors, including presenting symptoms, age, sex, smoking history, and past medical history, provided no predictive information for a pneumonia diagnosis.
The authors note that previous studies have found fever, crackles, and elevated pulse rate to be predictors for the presence of pneumonia. However, unlike the current best diagnostic model, the presence of a runny nose was not found to be significant in the present study. In contrast, the addition of pulse oximetry has demonstrated clinical utility in previous retrospective studies in the primary care setting.
The researchers acknowledge limitations to the study, primarily that thoracic radiographs were only obtained in a small sample of the full cohort and that those patients selected for radiography were more ill and at higher risk for pneumonia. This may have resulted in fewer reported cases of radiograph-confirmed pneumonia in the cohort as a whole, and as well as overemphasis of the importance of the four clinical signs as positive predictors of pneumonia.
Given this limitation, the study authors caution that, although pulse oximetry may have a role in the diagnosis of pneumonia, further studies that include comprehensive assessment, including thoracic radiographs, will be required.
Funding for this study was provided through a grant from the National Institute for Health Research. The authors have disclosed no relevant financial relationships.
Eur Respir J. Published online November 22, 2017. Full text

Shouldering the burden

Its so reassuring when you get taught by the person who's invented the procedure!

Get Coached!

If there is a doc you SHOULD listen to for worldly advice without prejudice nor agenda, it is Atul Gawande. In this TED talk, he extols the virtue of coaching. 

Common cold or apocalyptic strain?

Sometimes you can learn something even though its common. So make sure you're educated before you "educate" patients.


Away on holiday... sort of.

We haven't disappeared from the FOAM world but have been on hiatus for education and holiday reasons. Happy new year to all our readers!
Singhealth has been actively involved in EM and disaster medicine in the region for decades. Not only are Singapore doctors sent on relief missions but also for educational outreach in non disaster times. Here are a few photos from a recent trip to give our perspective to Nepal EM docs, nurses and administrators on pre-hospital and hospital disaster management.
On a personal note, it was heartening to go back to Kathmandu and its environs as the last time I was there was during the Nepal earthquake and much has improved both socially and preparedness wise.

Group discussion and pre-presentation work 
Outdoor hospital prep
Triage table tops

Field team bag preparation 
How to moulage for excercises

Team presentation on their preparedness plans

The "dreaded" assessment - can't have learning without it!

Group pic