Resuscitation of the crashing infant

An approach the the initial resuscitation of the critically ill child


It is your last of 3 night shifts, but so far it has been great. You successfully resuscitated a woman with severe postpartum hemorrhage. You got ROSC on a young cardiac arrest patient, and just heard that he is awake and talking after having his LAD opened in the cath lab. You even managed to get the Cunningham technique to work on a dislocated shoulder for the first time in your career. Now, during a lull, you are joking with the nurses, and someone says the work “quiet”. The next minute, the triage nurses is running down the hallway with a limp, blue 3 week infant in her arms and 2 very scared parents in tow…

Continue reading “Resuscitation of the crashing infant”

Hypertonic saline for elevated ICP (Articles of the Month special edition)

In the June edition of the articles of the month, I included a paper on hypertonic saline for the treatment of traumatic brain injury. My conclusion (and that of the paper’s authors) was that hypertonic saline did not seem to provide any benefit, either in terms of mortality, or even in terms of lowering intracranial pressure. My friend Scott Weingart pointed out that the paper might not actually support that conclusion. The problem was with the studies they included in the review (which I hadn’t read myself). This is probably an excellent lesson: reviews are nice as an introduction to a topic, but expert clinical practice really requires a familiarity with the original literature. For example, there are many reviews that conclude that tPa is excellent for ischemic stroke, but… well I guess I won’t get into that here. Anyhow, I promised to read the studies on hypertonic saline in a little more depth and post an update, so that is what follows.

Continue reading “Hypertonic saline for elevated ICP (Articles of the Month special edition)”

Articles of the Month (September 2016)

It’s time for another edition of the articles of the month. I didn’t come across as many papers worth sharing as I usually do, but there are still a few gems in there. The good news is it is a quick read. Once again, I will be discussing these papers with Casey Parker on the BroomeDocs podcast, and we would love to hear feedback about the audio version of these posts. Until next time….

Continue reading “Articles of the Month (September 2016)”

Making it Stick

I don’t know how much of what I “learned” in medical school I have since forgotten. It is a lot. Probably more than I remember. I did great on exams, but then it was time to move on to a new semester and piles of new information took priority over the old. There was no time to review or consolidate.

At the time, this just seemed like the way that learning was done. It wasn’t much different from my undergraduate routine: cram for an exam, get the marks, and move on to another topic. This was the way medical school was structured. The expert educators behind my medical school curriculum obviously knew what was best for me – right?

But where is all that knowledge now? Why did it feel like I had to start all over again in residency? Why do the residents I teach now, fresh out of medical school and close to that wealth of information, so often struggle?

We spend so much time trying to learn medicine, but we never really learn how to learn. This post is basically a review of the book “Make It Stick” by Peter Brown, Roddy Roediger, and Mark McDaniel.1 I wish I had been given this book before starting medical school. Actually, it would have been more beneficial before starting university, or even high school. It explains clearly why learning seemed so easy but ephemeral. I had excellent marks throughout high school and university – but if you made me take an exam from any of my past courses right now, I would almost certainly fail. Is that really learning?

These are the key lessons I wish I had learned long ago: Continue reading “Making it Stick”

Mending Medical Myths (lecture notes for St. Pauls Emergency Medicine Update 2016)

Medical myths matter. All of our decisions, although they often seem small to us in the middle of a busy shift, have real impacts on people’s lives. To be a truly expert clinician, you have to understand not just what to do, but why you are doing it.

The primary myth covered in this talk was the use of topical anaesthetics in the management of simple corneal abrasions. The full handout and list of articles can be found here.

First10EM corneal abrasion handout cover.png

I also covered Salter-Harris 1 injuries, the myth that ligament is stronger than bone, and that concept that not all of these injuries need a cast. A full handout with references on the topic can be found here.


If you are interested, a few of the other medical myths that I mentioned during the talk were:

The use of PPIs for upper GI bleeds

The benefit for stress testing in low risk cardiac patients

As physicians, we are trusted sources of medical information. We are relied upon not just by our patients, but also our families and friends to be knowledgeable and credible sources of information about health. We should all probably be aware of common medical myths, such as the need to drink 8 glasses of water a day, the idea that we only use 10% of our brains, or the thought that eating turkey might make you sleepy, because even these seemingly benign misunderstandings can have tremendous impacts on people’s lives. For a short, fun read on some of these topics, see:

Vreeman RC, Carroll AE. Medical myths. BMJ (Clinical research ed.). 335(7633):1288-9. 2007. PMID: 18156231 [free full text]

Charles Sidney Burwell, the dean of Harvard medical school at the time, famously said, “Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.” This may still be true today, but I don’t think this has to be true. If we taught the complexity of science, rather than just a collection of facts, we wouldn’t be wrong. We would understand the need for replication of studies and the limitations of p values. We would be able to differentiate treatments with great evidence (ASA in MI) from those with bad evidence (tamsulosin for renal colic), and we wouldn’t be so surprised by the constant updates that are part of the normal scientific process.


There is a lot of evidence to keep track of and not many of us are laden with free time. How is one supposed to keep up with everything? In this day and age, I think the answer is crowdsourcing the work. There are so many great, free EBM resources available not that I don’t think there is any excuse in falling behind. This handout covers my favourite sources of evidence based medicine and critical appraisal.


If anyone takes up my challenge and finds an interesting answer while exploring why we do what we do, feel free to contact me and we can share it here with everyone else. You can use this contact page or else e-mail me at first10em at gmail dot com.


Emergent Cardiac Pacing

How to set up emergency cardiac pacing


The 67 year old bradycardic patient from the previous case has a heart rate of 38 and a blood pressure of 68/45. It is time to start pacing… Continue reading “Emergent Cardiac Pacing”

Managing unstable bradycardia

A brief overview of the initial management of unstable bradycardia in the emergency department


A 67 year old man is brought in by EMS after a syncopal episode at home. He has only partially regained consciousness, with a GCS of 12. His wife says that he has had a fast heart rate before and that he also has diabetes and high blood pressure. She isn’t sure what medications he is on. He has had flu like symptoms for a few days. The paramedic vital signs were a heart rate of 38, a blood pressure of 69/45, a respiratory rate of 22. The oxygen saturation tracing has been inconsistent, but they think it is probably about 91% on room air… Continue reading “Managing unstable bradycardia”