whats happening in the EM world

the educators' blog: 

an online journal of whats impotant in emergency medicine, specifically as it relates to our local practice in the Hunter New England Area. please post comments via the 'post new entry' and upload any files into the appropriate folder under 'files'. 

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Are you sure you want me to see this patient?!

The case:

52 year old man presenting with a 5/7 history of diffuse lower abdominal pain

He had been febrile for 3/7, had some nausea and vomiting and had not opened his bowels for 5/7.

He was otherwise well with no regular medications or past medical history

On examination he was febrile to 39 degrees celcius, tachycardic at 108 bpm with a peritonitic abdomen.

Surgeons were consulted and a CT scan organised.

Bloods had been taken before I reviewed the patient and were pending.

Prior to the CT scan the surgical registrar arrived to review the patient and had a look at the bloods which included a high sensitivity troponin (?!)

Unfortunately, this was elevated at 461, prompting the question above.

I was quite surprised by this reading and went back to reassess the patient.

He denied any chest pain, and was very fit and active with a good exercise tolerance and no risk factors.

Serial ECG's were performed (normal) and a repeat troponin was taken which was still elevated at 161.

The on call cardiologist was then consulted who advised that this was a false positive test and that we should disregard the troponin.

Like most of us I am still trying to get my head around the new HS troponin assays.

I was lucky enough to attend the SMACC conference this year and heard Louise Cullen and Rick Body speak on this issue.

They were both of the opinion that the HS troponin is very specific for heart damage (and shouldn't be raised at all if the heart is not affected) and if there were elevations it was due to an insult of some sort (though not necessarily ischaemia).

Based on that logic it would seem that the patient must have had a type 2 myocardial infarction....but I'm still quite sceptical that this occured in the patient given how fit and healthy he normally was.

Would be very keen to hear others thoughts and in particular if they had any information on this issue!

The patient subsequently had a CT that showed a perforated appendiceal abscess and went to OT where he was found to have 4 quadrant peritonitis with multiple adhesions.

He was discharged 6 days later and has been fine since.


TAPNA 2014

G'day All,

On April 30th till 3rd May Newcastle will once again host the Toxicology And Poisons Network Australasia, TAPNA, scientific meeting. The plenary sessions will include talks on marine poisoning, the latest in redback envenoming following the RAVE II trial and a session on addiction medicine. Go to www.tapna.net for information. 

On Saturday 3rd May we will be running a one day Toxicology workshop aimed at ED/acute care trainees, final programme will be on the website within the next week. Early bird price is $250.00 Hoping a few of you can make it. This is the weekend of the fellowship clinicals so obviously those involved in that won't be coming but everyone else !!!

Finally, the slideshare website through which I put up some of last year's talks as well as Sam Vidler's presentation from last year, is going to discontinue the slidecast service soon. This means that after April you won't be able to access any of the audio-visual presentations. I am hoping to have these (and some more talks) up on a different platform soon.




neonatal urine collection

.....just wondering if anyone has tried tapping out a babies urine?...



(post on AliEM)



The Case: A 8-day-old, uncircumcised male is brought to the ED with fever, irritability, and decreased urination.
The Problem: Getting a clean catch urine in a timely, non-invasive manner
The Solution?

 Trick of the Trade

  1. Provide oral intake to the neonate
  2. 25 minutes after feeding, clean genitals with soap and water; dry with sterile gauze
  3. Give non-pharmacologic analgesia (Pacifier or 2% sucrose syrup)
  4. One person holds neonate under the axilla with feet dangling
  5. Another person starts bladder stimulation with gentle tapping of the suprapubic area (100 taps/min) and stimulation of lumbar paravertebral zone (light circular massage)
  6. Perform steps 4 and 5 for 30 secs at a time, as many times as needed
  7. Catch midstream urine sample in a sterile collection container

Study Publication [1]

  • Study methodology:
    • Prospective feasibility and safety study
    • Single center in Madrid
    • 80 neonates (31 girls and 49 boys)
    • Mean ages: 6.66 day old boys and 6.23 day old girls
  • Results:
    • 86% success rate in obtaining urine in
    • Mean time for sample collection: 57 sec
    • Mean time spent collecting samples in males: 60.48 sec
    • Mean time spent collecting samples in females: 52.04 sec
  • Limitation: Lack of control group
  • Conclusion: Based on a previous study using a vibrating bladder stimulator [2], this manual method to obtain midstream urine in newborns is safe, quick, and effective.
Screen Shot 2013-04-17 at 11.00.35 PM copy


Urine collection in neonates is a time-consuming and unpredictable task that requires time and attention. Although a small study, this new technique does not cause discomfort or waste time as is typically the case with catheterized urines and bag collection methods, respectively.


  1. M.L. Herreros Fernández, N. González Merino, A. Tagarro García, B. Pérez Seoane, M. de la Serna Martínez, M.T. Contreras Abad, and A. García-Pose, "A new technique for fast and safe collection of urine in newborns.", Archives of disease in childhood, 2012. http://www.ncbi.nlm.nih.gov/pubmed/23172785
  2. P. Davies, R. Greenwood, and J. Benger, "Randomised trial of a vibrating bladder stimulator--the time to pee study.", Archives of disease in childhood, 2008. http://www.ncbi.nlm.nih.gov/pubmed/18192318

ED drinks

Hi everyone,
It has been a while since we had end of term drinks in ED. It is always tricky to get everyone there at once of course with shift work, exams, kids and life in general. But what about we give it a try in 2014?? A few people will be leaving hne or leaving ED next year and I thought it wd be nice to meet up before next term.
What about drinks on Friday 31/01/14??? I am afraid I can't really recommend a good drinking spot though. I will leave that decision to the more experienced drinkers...
Have a safe and happy Christmas and New Year!!!

Sent from my iPhone



Anaphylaxis 4

This is the fourth and last instalment of Simon Brown's anaphylaxis workshop from TAPNA 2013. It covers treatment so the most clinically relevant. Goes for about 20 minutes. 

Click here


Latest Critical Care research - Practice changing?

Gajendragadkar and colleagues undertook a multicentre, prospective, covert observational study, examing the survival times of chocolates (n=258), both Quality Street (Nestlé) and Roses (Cadbury), on four UK wards, and found:

  1. 191 out of 258 (74%) chocolates were observed being eaten
  2. mean total observation period was 254 minutes (95% CI 179 to 329)
  3. median survival time of a chocolate was 51 minutes (39 to 63)
  4. chocolate consumption was non-linear, with an initial rapid rate of consumption that slowed with time
    • an exponential decay model best fitted these findings (model R2=0.844, P<0.001)
  5. survival half life (time taken for 50% of the chocolates to be eaten) was 99 minutes.
  6. mean time taken to open a box of chocolates from first appearance on the ward was 12 minutes (95% CI 0 to 24)
  7. Quality Street chocolates survived longer than Roses chocolates (hazard ratio for survival of Roses vs. Quality Street 0.70, 95% CI 0.53 to 0.93; P=0.014)
  8. percentages of chocolates consumed were by
    • healthcare assistants (28%) 
    • nurses (28%)
    • doctors (15%)

Full Text:  Gajendragadkar. The survival time of chocolates on hospital wards: covert observational study. BMJ 2013;347:f7198


THIS is the point I was trying to make...

for those of you who were present at thursday teaching session, I gave a talk on using the FOAMed resources more then wasting your time attempting to critique articles and used the TTM trial published recently as an example....  leave it to someone from NZ to make the point much more succint then I?   see below.  but you should get in and be a part of the discussion, say, at next thursday M&M journal club where the TTM trial is going to be discussed... cheers.scott

great quote:

For the new docs I (this is heresy) recommend you don’t spend too much time reading original research.  You have too much to learn, and you need to get the big picture and not get lost in the detail.


here is my talk and resources used: click here


52 articles in 52 weeks: Landmark EM articles

In case you didn't see this on ALiEM, nice that someone has collated them. Not necessarily all relevant to our day to day practice but maybe worth picking out a few to be familiar with. I like the 'one a week' concept, makes it seem more manageable. 



Which antihypertensive is best?

I am leading a discussion on hypertensive emergencies and want to know the preferred agents of particular senarios amongst us, here in HNEH:  please anonymously feel out the short 10 question survey below


Create your free online surveys with SurveyMonkey , the world's leading questionnaire tool.



Fellowship Exam and #FOAM, HETI masterclass Nov.1, 2013

Here is the powerpoint as well as access to the majority of my ankiweb flashcards, additional notes, questions, and the feedly 'OPML' file to gain access to all of my FOAM sites..... 

powerpoint presentation found: HERE  

(remember, link to websites in my talk can be found by opening presentation and clicking on 'screenshots' of wanted website within the powerpoint presentation)

ankiweb flashcards: 

instructional word doc found: HERE

flashcard file to download and open in desktop version of ankiweb program: HERE


instructional word doc found: HERE

'OPML' file to import into feedly once you sign up for an account: HERE 

(this OPML file will work in any and all other RSS/feed reader programs)

My collection of fellowship notes:

found on google drive and free to download: HERE

(apologies to those who can not access google drive at their places of work. It was the easiest way for me to allow multiple people to have access to download. If you have a google account, I recommend you 'add' this fellowship folder to your 'drive'. This will give you the ability to download entire folders of files as opposed to individual files.)


I truely hope this helps everyone and good luck!

(please don't judge, my brain works in myseterious ways sometimes)


scott flannagan,

recent successful candidate of the ACEM fellowship Exam, 2013


CME Meeting - Damage Control Resuscitation 

Hi all,


Late notice but the Dept of anaesthesia has an interesting meeting on this coming Monday at RNC. See below


Department of Anaesthesia - CME Meeting

Date:  Monday 28th October 2013
Time:  7:00am
Venue:  RNC Lecture Theatre

Speaker Dr Peter G Moore - Damage Control Resuscitation - "An Old Idea Made New Again".





Anaphylaxis part 3 Pathophysiology 

Third part of anaphylaxis talk now available



In June the CMN teaching session featured a recording of a workshop by Professor Simon Brown from Western Australia. This talk was long and split into 3 parts and very comprehensive. Currently 2 of the 3 parts are available in a slightly different format via the links below. Part 3 will follow in due course.

Anaphylaxis part 1

Anaphylaxis part 2


Teaching Session held at CMN on 29/08/13

For those of you unable to attend OR who wish to review again


  1. Case Presentation 'Bradycardia' by Sam Vidler Part 1 Click here 
  2. Case Presentation 'Bradycardia' by Sam Vidler Part 2 Click here



new website for those gearing up for another season of primary/fellowship exam study

check it out under our useful website section