Differntiate pleural effusions on CT!

Great video by Medmastery. Learnt so much and hope you do too. Support their channel and view their other great meducation posts.  

Webucation 22/10/17

This edition of web wisdom encompasses mythbusting in trauma and radiology. Also a tour de force in dissections and finally a must hear podcast if you work in medicine at any level - all about UTIs. 

• Grow a spine... or don't
• The intoxicated C-Spine
• All about the aortic scourge
• Contrasting myths
• Do you really need to do a pelvic exam?
• But the angiogram was normal!

• You think you know UTIs?

The last podcast will stun you. not because its a sexy topic but maybe because it will make you remember the relevant issues in a most common presentation. Test yourself - do you know how to handle UTIs?

Webucation 24/7/16

This edition of webucation was slightly delayed due to holidays but we're back with pearls from surgical trauma, cardiology updates and even a funny xray of sorts... As always visit and support the content creators.

• Best site for a chest hole? - Location location location
• What aside from the STEMI? - Great learning points in the end
• A thorny issue - Desert hands
• CPR & amiodarone - Drug free CPR?
• Pelvic trauma -A great mini review
• Scan pan? - Saving lives for a living or something else?

• Top 10 errors of procedural sedation - The top 10 list of shame!

That last list is a solid reminder that although sedation is COMMON in EDs, it is far from safe. Buyer beware and make sure you got one of these before you start!

Webucation 2/7/15

Web wisdom this edition comes from areas of urology, general surgery, trauma and paeds. As always, give credit to the content creators.

• Teaching practical skills - Can you set it up like this?
• St Emlyn's top 10 trauma papers 2014-2015 - Just like Letterman's, but in EM
• Is it peritonitis? - How good are your hands?
• Swan song for tamsulosin? - A rolling stone no more
• STEMI or not? Here I come... - One formula to rule them all
• Emergucate's imaging case - What are  the chances?
• Stop crying! - Is not the right thing to say in these circumstances

The last link is a gem in mnemonics. It also has a great Rule of 3's for infantile colic. Great site for paeds. Do visit it.

Webucation 16/2/15

This edition of web wisdom comes from the domains not just land based radiology and paediatrics but also a gem of a myth-buster from the air. Soeaking of air, LITFL does quick work on something familiar. Pls credit the original content creators when able.

• Did you spot it before clicking ? - Be honest!

• Imaging case of the week - Think laterally man

• Algorithm for knee - Why not we say.

• PTX time for change? - All this tension over a cannula.

• Sports name - What eponymous sport is the answer?

• Paeds inguinal hernia - its not just the old men who get this.

Your lungs will no explode - Aeromed myth busting finally

The last link is another great piece of dogma lysing which is all too common these days with the advent of sensible, pragmatic studies which are permeating our profession. Long may it continue.

Webucation 17/1/15

This edition of web wisdom brings you weird and wonderful and in rainbow colours as well. Be sure to credit the original content creators.

• Cough CXR? - Sometimes even bad things come in three's.
• That's a big tummy - Think you know your kid abdo xrays? Try this one.
• Ventilation in severe asthma - Can you get out of this difficult position in the future?
• Blue vomiting? - Cos who knows when this will show up...
• Dont i+d that paronychia - That's no moon, its a whitlow!
• Bronchiolitis 2015 - Finally a simplification we were all waiting for.
• Anti-CT top 10 - Ban pan scan man.

The last link provides yet another example of how the world is collectively wisening up to the dangers of irradiation and importance of wholistic care.

Webucation 12/10/14

Web wisdom this time comes from the realms of trauma and radiology mostly. There's also a treat for Star Trek fans and airway enthusiasts all wrapped in one funny promo...

• Name the fab four features - Radio Signs tests our mnemonic powers.
• Lace up your diagnosis - What obscure disease causes this one? Test yourself.
• When a subdural needs surgery - Something we always wanted to know made clearer.
• Choosing wisely - Recommendations which are sensible and borne out anecdotally.
• Big bay is better? - Which one is yours? I know mines the tiny one...
• Is my sedation cocktail off? - Ketofol ratios (finally) for those who like using this combo.

• Kobayashi Maru in the ED 

The last link was a promo for the SMACC conference. Semi decent lip-synching but the medical satire is pure gold. Admit it... this has happened in your ED in some shape or form!

Webucation 1/9/14

Lots of cold things in the following musings from around the web. From the realms of trauma to radiology to EBM. As always credit to the original content providers.

• On your knees - Emergucate truly educates with this one. Am partial to this as I suffered from this one!
• Shoulder this burden - The much taught and rarely seen shoulder lesion.
• EBM - a movement in crisis? - A great read for enthusiasts and detractors of the current state of EBM.
• Is my hand broken? - If it is, can you tell clinically?
• Ice pack ahead - Does this simple humble intervention actually work?
• Boy its cold! - Larry Mellick provides a great view into the world of actual severe hypothermia.
• PR disaster - the trauma pro eulogizes the PR. We say RIP.

The last link gives another chance to chime in on our pet peeve. Rectal assault on conscious trauma patients with normal neurology is archaic practice. Dare you step into the 21st century? Or more importantly - will you allow your trainees to? 

SEMS 2014: Angeline Poh - Coronary CT

Coronary CT is a fast evolving modality for risk stratification in modern EDs. Dr Angeline Poh is a radiologist at Changi General Hospital and she gives a practical synopsis on the current state of play.

Webucation 10/6/14

Web wisdom this time comes from the realms of microbiology, paeds, radio and even some good ol' pharmacology. Remember to support the original content providers.

• 5 CC articles - The Rebel EM gives us his top establishment studies!
• The culture in cellulitis - ALiEM lyses a great myth regarding cultures in cellulitis. 
• Ketamine analgesia - I know, I know... Another article on ketamine? Have you read our blog title?
• DKA myths - The EM Swami on modern DKA management and the mistakes that some Drs make.
• Routine pre-op - Test yourself. Can you spot it?
• Little commotio cordis - Heart stopping hits from Paeds EM Morsels.

• Log roll finger bum ? - More dogmalysis on a topic we've been trying to bury for a decade now. Is it really necessary to rectally relieve ALL or ANY of your patients???

The last point mirrors our opinion as well. I cannot recall doing a DRE on a conscious, neurologically intact patient for years... its time we all spread the myth-busting surrounding the anal abuse in EDs! 

Webucation 29/3/14

We're happy to be back and we bring you some tasty bits of med-ed from the realms of paeds, ob/gyn, surgery and even some philosophy. Credit as always to the content creators.

• Shock in early pregnancy - Chris Cresswell's excellent pathway/guide for bleeding in early pregnancy
• Neonatal analgesia - Should children really be deprived of this based on whim?
• Abc easy as 123? - Ryan Radecki asks is ABCD3 is what you need
• Is it just culture? - Do we really need to keep doing this for everyone? ... Bug bear of mine.
• A what lesion? - The Trauma Pro shows us a lesser known disease. 
• Under the dome - Why is the dome gone?
• More TPA debate - great debate on stroke lysis. Pros and cons all laid out for you.
• Dogmalysis - Cliff Reid's homage to myth busting.

The last link is close to our hearts. We deal with such "traditions" day in/day out. We thank such innovators in bringing to light the remedies in such scientific form.

Webucation 9/3/14

Lots of kids and imaging pearls in our dive into web resources this time.

• Hit the nail on the head - Ryan Radecki asks if some hammering antibiotics are really necessary?
• Score 1 for the HEART -  Salim wonders if we should be moving on with our risk stratification tools
• No need for speed - Excellent tutorial on subtle injuries on CT in high velocity accidents
• Leave those kids alone! - Scancrit talks about the insult to injury by irradiating kids
• Imaging at Emergucate - Pop goes the weasel's hip?
• The 1-2-3 of..? - Can you spot this pathology at Radiopaedia
• Ouch it hurts down there - A great Morsel on ovarian torsion in children.

Radiation bomb - Scancrit drops the bomb on spinal immobilisation. We say about time to! We are once again grateful for such myth busting. While we are on that trail ,common sense also tells us that lying on a metal trauma board in the trauma resus bay with a collar and no neck support is NOT THE NORMAL ANATOMICAL POSITION.... so why do we persist? 

Webucation 17/2/14

This round of web publications comes from wonderful websites talking about paediatrics, radiology, neurosurgery and even some pharma thrown in. Be sure to visit the content creators.

• One of these things is not like the other - when is SAH not an SAH? Dare to discharge?
• LBBB STEMI? - Steve Smith shows us that LBBB is not always so.
• Frusi juice in APO? - Is this Rx REALLY warranted anymore?
• Kids CXR - Pratibha from Emergucate highlights a really educational paediatric CXR
• Dose me properly - Have we been drugged into flatly dosing vanc for years?
• Tramadol - when to avoid it -  the headline says it all - dirty drug!
• A morsel on meningism - Paeds EM moresels reminds us how important it is to keep a high state of vigilance for meningococcaemia.

Another radio myth? - Can we finally let go of this myth? 

Difficult though it may be to admit that we have been misled all this time. Could it be that we finally need a cross specialty study to finally end this conjecture -  for future generations sake...

Webucation 25/1/14

Web delights this time emanate from paediatrics to radiology and also to myth busting of the highest quality.

• You're too slow kid. - A great morsel on paediatric bradycardia,
• Wrong answer mister - So you think you're good or are you really that good?
• Circular blockers? - Steve Smith asks - have we indeed done the 360 on beta blockade?
• The ketamine brain continuum - you know we couldn't resist this exposition on ketamine... I mean our website name is sort of an homage to dissociatives!
• Stroke Series - Radiology Channel's excellent run down on hypertensive bleeds on CTs
• Is it really necessary to do postural BPs? - Great myth busting orthostatic measuring! Thanks to LITFL for this vid.

• BIphasic what? - Ryan Radecki plays down this over reaction on the overreaction myth.

The last link allows us to give kudos to the internet myth busting crusaders. Nice to know technology is helping us move forward and away from tradition based medicine.

Webucation 23/10/13

Web wisdom this time encompasses the fields of paeds, surgery, orthopaedics and a whole lot of radiology. As always, support the original content providers.

• Cavity mnemonic - Radiopedia gives us a great memory aid for cavitating lung lesions
• Typhlitis - What?? That's what I said... Paeds EM Morsels talks about necrotising abdominal pathologies
• How to confirm ankle joint penetration - Interesting stuff... use the blue!
• MBA accident - Know your trauma c-spine films? Do this test then.
• How bent can we leave it? - Just how bendy can we leave paeds #s?
• The death of decorum - Greg Henry decries the death of decency
• Death from thousand clicks -  The time saving devices are a phenomenal waste of time

• 10 tips for approaching abdominal pain in the elderly - ALiEM puts this much discussed topic succinctly.

We here echo this last link as a great reminder to all trainees and professionals of the high morbidity and mortality of abdo pain in the elderly. Our guide can be found under "Useful guides" above and here is the direct link for your reference. Have a high threshold of suspicion always.

You have air in WHAT?

Any condition preceded by the term "emphysematous" is generally a bad thing to have. Whilst considered relatively rare, these are important conditions to diagnose and can be detected very well with conventional imaging techniques. They classically all occur more commonly in diabetic patients and are more typically related to infection than ischaemia.

Here is a collection of cases where air in the wall of an organ is evident on imaging.

Emphysematous Cholecystitis

This 52yo diabetic woman presented with non-specific abdominal pain. No previous relevant surgical history or old imaging was available. Following cholecystectomy she had multiple episodes of cholangitis following this acute presentation.

There is a rim of gas outlining the gallbladder in the right upper quadrant; this was effectively an abscess completely filling the gallbladder, with gas penetrating into the necrotic gallbladder wall

Emphysematous Cystitis

This 39yo female patient presented with right-sided abdominal pain, guarding and generalised sepsis. She subsequently went into renal failure and required cystectomy and ileal conduit formation.

The structure in the anterior pelvis containing gas in the wall and a large gas-fluid level is the bladder

Emphysematous Gastritis

This 91yo male patient presented with AF, melaena and haemodynamic instability. Things went downhill quite quickly from here.

3 arrows on this coronal CT highlight gas within the wall of the stomach, small veins leading away from the stomach, and intrahepatic portal veins

Emphysematous Pyelonephritis

This 48yo diabetic patient presented with hyperglycaemia and abdominal pain. She eventually recovered without surgery but with significant scarring to the left kidney.

2 arrows on this coronal CT demonstrate the location of gas within the renal capsule superiorly and in the proximal ureter

Webucation 13/8/13

Web musings come from abundant surgical sources this time. Enjoy the readings and always support the original content providers.

• Always check what you ordered - the Trauma Pro reminds us that philosophy is similar in restaurants and hospitals
• Surgical or medical jaundice or something-else - another illuniating video by EM tutorials
• CT in stab wounds - do you really need to?
• Sciatica therapy - maybe a rethink what you thought is essential examination?
• Haematuria management - A brief rundown of bloody urine in the ED
• Fluid responsiveness - ED Lyceum gives us some collective knoweldge on this ongoing fluids debate
• Contrast induced nephropathy - EDTCC gives us a great run-down on this controversial topic. Certainly there has been a tendency to err on the side of caution by radiologists but is there any REAL evidence for what we do?

What we do in our practice is that we look into all the factors (some latent) when deciding who needs a scan with contrast:

1. Age
2. GFR - more so than creatinine
3. Pathology in question - can it be observed rather than immediate diagnosis now?
4. Renal disease?
5. Non contrast scan - you will be surprised at its utility

Feel free to comment or ask your friendly radiologists to if they have an opinion.

A pair of paedias

Many of you may already know of this site, but just in case you haven't seen it yet, check out Radiopaedia, a collaborative free radiology educational archive:

http://radiopaedia.org/

They have also recently updated to include:

• youtube channel for radiology
• tumblr feed of radiology signs
• pinterest pin board of cases
• instagram page of cases

And while we're at it, there is another lesser known "paedia" dedicated to ultrasound imaging, with instructional pictures and videos as well as examples of anatomy and pathology:

http://www.ultrasoundpaedia.com/

Unfortunately some of this website requires payment but there is still a lot of free information available.