Story#14 Hulk Hogan’s ear wave & Compassion

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If you have watched Hulk Hogan wrestling, you would know he has been a hero to many. Among his many sensational moves was a signature “ear wave”. Take a look

Before the Hogan decides to take on the the poor referee, he performs his ear waves where he walks to all 4 corners and “LISTENS” to the crowd. He makes them feel important. He is indicating it to them that “I am a world champion but I am “LISTENING” to you”.


A 29 year old female presents with abdominal pain and increased work of breathing. She suffers from type 1 diabetic. Her blood ketones are 6.1 and blood gas shows

pH 7.15 HCO3 15 Glucose 29 mmol Base excess -12 Lactate 1.6

The conversation between the “Doctor & Patient” was as follows

Hi..My name is  “dr fast & the furious”. How can I help?

Well Dr I have diabetes and

Do you take insulin?

Yes I am on insulin but yesterday I was feeling poorly. I had this terrible belly pain & felt like..

Did you had any vomiting…

No but I was…

any diarrhea…


burning urine…


Chest pain..



No…but Doctor I was saying that I felt nauseous yesterday and didn’t wanted to…

Have you been taking your  insulin regularly..


Okie I am just going to review your blood results and will come back to you..

Doctor reviews the results and makes the correct diagnosis of Diabetic Ketoacidosis, writes the correct management  and refers the patient to medics. He then carries on seeing other patients and doesn’t get time to get back to this patient. She goes to the ward, gets better gradually and is discharged 3 days later. After few  of weeks later, ED department receives a complaint letter that says…..


I would like to express my concerns regarding the contrast in  care I received between emergency department and the medical ward. As soon as I reached ward, doctor explained to me what was my condition, listened to me and treated me. I started feeling better after few hours. I felt the doctor in ED acted more like a traffic warden who just directed me to medical ward .I felt I was not listened to. How could the doctor have diagnosed me when we wasn’t even listening. I understand the busy and noisy nature of A&E but strongly feels that ED doctor should have spent minute or two to listen to what I had to say.


ED compassion is as important for patients as giving good clinical care. Though there are many scientific papers and theories behind ED compassion, true delight of compassionate care comes from an introspection. Here is what I have found by listening…

5 lessons learnt

Be an ED hero

Have a listening ear

Let your patient know

You have time to hear

So next time when you are treating your patient,                         ask yourself have you listened?


Story 13 Crashing dissecting patient and ultrasound chick

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On one fine Sunday afternoon at Storifield Royal, a pre alert was received from paramedics

” 77 year old male has had a sudden onset of severe back and bilateral leg pain an hour ago. Now he cant feel his legs. He is too agitated due to pain so we have not been able to record any observations. Patient looks pale and unwell. ETA is 5 minutes”

So we geared ourselves up to receive the patient with likely dissection. Here is the timeline of this case.

00:00 Patient arrives to ED

00:01 Monitoring ,O2 applied. 2 x large bore IV inserted.Blood sent

00:03 Analgesia prescribed. P 118/min BP 105/66 

00:05 ECG done. Ultrasound performed.

Longitudinal view of aorta showing dilated aorta with false lumen. Intimal flap of aorta can be seen moving with cardiac contraction. Slide2Figure 1: Longitudinal view showing the dissecting flap separating the true and the false lumen.


Figure 2: Transverse view. Aortic Aneursym measuring 5.1 cm

00:07 Surgeons and ITU bleeped

00:08 Patient arrested. PEA followed by asystole

00:16 CPR discontinued

These epic 16 minutes tells the story  why dissecting aortic aneurysms are ticking time bomb.

Rapid.Ultrasound in.Shock(R.U.S.H) examination can promptly diagnose life threatening causes of shock in ED.


rush 2

Read in detail about the RUSH exam by following the links in foot notes.

RCEM recently has raised awareness regarding missed aortic dissections

rcem alert



The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll.

Rapid Ultrasound for Shock and Hypotension – the RUSH Exam

RCEM alert




Story 11 Situational Awareness: From Bean to Spiderman in 2 minutes

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“Situational Awareness” or shall I say lack of…

So this is what happens when I lose “Situational Awareness”

& this is why “Situational Awareness” is essential.

This is a kind of junction I used to cross during my college days. All I had to do to keep my  “Situational Awareness” was to look 1-left, 2-right, 3-straight, 4-back mirror, 5-both side mirrors, 6-repeat all steps every 5 seconds. I wondered if this could be applied in Emergency Department to gain Situational Awareness!

So here is the story of one fine Resus shift


Situational Awareness has 3 components


A commonly used tool in US air force pilots to gain situational awareness at speeds of MACH 2  is OODA loop. Though we don’t break sound barrier, but sometimes the speed with which new patients arrives to Resus is not far behind.


So I applied this to my situation. Here is an example


and there I was…From BEAN to SPIDER-MAN in 2 minutes




Airmanship (Book)

Situational Awareness(Wikipedia)

Human Factors and Quality in Resuscitation(Resus Council)


Story 10 Paracetamol Clock

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At your finger tips… ” WHAT actions to take WHEN at WHAT times” in paracetamol overdose(click to enlarge).



Paracetamol overdose performa(Martin Wiese)

Story 9 The curious case of Cyclical Vomiting

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28 year old women known to suffer from “Cyclical Vomiting” presented to ED as she felt poorly. Vomiting a dozen times daily was a routine but today was something different. She had thrown up >20 times in a day.

Her initial observations were

Pulse 127/min BP 95/59 SpO2 93% on air

Abdomen was tender in epigastrium with no guarding. She appeared severely dehydrated.

Initial blood gas showed

pH 7.2

HCO3 16

Base excess -11

Glucose 7.8 mmol

Lactate 9

Urea 8.1 mmol/L

No obvious cause of shock was recognised. Pt was resuscitated with IV fluids and was given broad spectrum anti-biotics.

Significant lab results were

Urea 8.9 mmol/L Creatinine 136 umol/L GFR 39 INR 1.2

After 3.5 litres of fluids, repeat ABG showed

pH 7.14 HCO3 13  Base excess -10 Glucose 14 mmol Lactate 11.5


So glucose was rising, acidosis was worsening & lactate was creeping up. ketones were tested which were high (6.6).At this point, patient was started on DKA protocol as she met the criteria(hyperglycemia, ketonemia and acidosis).

But this wasn’t a simple DKA. Patient was in multi organ failure with high lactate and refractory acidosis. CT abdomen was arranged and ITU were involved.


Fig 1 Large amount of free air can be seen in the pancreas

This was a case of necrotizing pancreatitis associated with DKA and multi organ failure as a complication.She was taken to ITU where she made a gradual but full recovery.

moral 1 of the story 9



Case report

Case series


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Okie so this clearly didn’t go well. The Reg needs a feedback on how to deal with juniors. But How, When and What needs to be given as a feedback is an art.




Many models are available for Feedback but try to keep it simple, flexible and logical.The Pendleton model states



Inspired by:

Giving feedback in clinical settings

BMJ 2008; 337 doi: (Published 10 November 2008) Cite this as: BMJ 2008;337:a1961



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slide 2

Slide3Slide4slide5 (2)Slide7Slide6


Aviation Knowledge

Flight Safety

Critical phase distractions in anaesthesia and the sterile cockpit concept

Book: Clinical Research for the doctors of nursing practice

Comparing patient safety to airplane, formula 1 safety

FOAM EM Simon Laing

Scott Weingart on S.Hitters at RCEM SCIENTIFIC CONFERENCE 28TH Sept

Anaesthesia Trauma and Critical Care(ATACC)


Story 5 Can’t breath, Can’t talk

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03:00 14th October 1937 A&E Storifield Hospital

It was a  quiet night when the Resus phone went off. “We have a 59 year old male who developed sudden onset of shortness of breath an hour ago. He was “tripoding” when we arrived and saturations were 81% on air.On 15L SpO2 are 89%. He had no history of chest pain , cough, fever or any other medical conditions. Wife says he smokes a pack of 20 a day. He can obey commands but is unable to verbalise due to severe SOB. Pulse 115,BP 162/75,RR 45/min. We will be with you in 12 minutes.”

So we started our preparation. Possibilities like pneumothorax, asthma attack, pulmonary embolism and a cardiac event were discussed. 2 minutes later, the paramedic called back and said he is now unresponsive on AVPU scale. Bad feeling started to creep in. The speed of his deterioration mimicked ALS exam scenario. The patient arrived. I did the primary survey.


B:Silent chest bilaterally. Minimal expansion, symmetrical, Trachea central. SPo2 83% on 15L NRB. No stigmata of tension pneumothorax

C:Cold peripheries. P 123/min BP 162/89 S1+S2 audible

D: E1M4V1 Pupils 5 mm Bilateral and equally reactive.

E:NAD Temp 36.1

ABG: pH 6.98, pCO2 16.02 kPa, pO2 21.7 kPa, HCO3 27.8 mmol/L, base excess −7.5, lactate 2.7

BVM ventilations were initiated.He was cannulated and IV fluids started. RSI performed. Grade I intubation.

12 lead ecg and CXR were done next.



In the presence of silent chest,type 2 respiratory failure and no obvious pneumothorax on the x-ray, he was given 500mcg IV salbutamol but with a question that this patient had no prior history of asthma.Xray and ECG couldn’t explain the patients condition.

A RUSH(Rapid Ultrasound in Shock) was performed looking at the heart IVC and AAA. Echo clip is shown here.


A suggestion to perform CT head was discussed. But with a clear history of shortness of breath ,globally hypokinetic left ventricle and a GCS that dropped later, a collective decision to activate the cath lab was taken without performing a CT head. Angiogram showed severe left main stenosis which was successfully stented

So summing it up, this man had an occlusion of left main causing acute coronary syndrome and global hypokinesia of left ventricle leading to flash pulmonary edema. This led to severe bronchospasm , the silent chest and respiratory.

He was discharged home a week later.

learning tales story 5

Inspired by

Acute coronary syndrome(BMJ case report): A rare presentation