A flutter name erased

Renal failure, hyperkalaemia, tachycardia. What’s going on?

A 67-year-old with a Hx of dilated cardiomyopathy, atrial fibrillation and obstructive uropathy presented after a collapse at home.  He said his urine has been white recently. His temperature was 37.9 in the ambulance, 37.4 in ED. He was tachycardic at 125, BP 90/60 (it had been 69/49 in the ambulance, in dropped again 81/60 […]

Inferio posterior STEM

Burn this ECG into your brain

63-year-old male with 5 hours of central chest pain   What is the diagnosis?   Click for answer   This is a posterior and probably inferior STEMI. Anterior ST depression is a posterior STEMI (or a Sgarbossa +ve STEMI in the presence of LBBB) till proved otherwise. To confirm that the anterior ST depression is […]

R main stem intubation

The crashing intubated patient: DOTTS

Whenever a patient you have just intubated deteriorates, or a patient on a ventilator deteriorates quickly: DOTTS Disconnect and let them exhale: This gets the ventilator out of the equation and simplifies things / reduces our cognitive load: we understand BVMs (bag-valve-mask), ventilators and circuits confuse and scare us.  It also stops ventilation for a […]

Sgarbossa 10.13.23 pm

LBBB and Sgarbossa

  Left bundle branch blocks cause a lot of confusion. People often mistake the normal anterior ST elevation of LBBB as an MI Less frequently people miss significant concordant ST segment changes which may be a STEMI (by Sgarbossa Criteria) The Law of Discordance or the Law of Appropriate Discordance In a normal LBBB the […]

5 lessons

The future funding of FOAM

Free Open Access Medical Education or FOAM has been free to users and producers largely due to the generosity of this man the Godfather of FOAM, Mike Cadogan. When I last spoke to him over a year ago, he was pouring over $75,000 a year of his own money to pay for technical support, Word […]

Military trauma

Trauma: Lessons from the Military. Wing Commander Dr Paul Nealis

    Key points Stop bleeding! Tourniquets are great. Pack bleeding wounds firmly.  A roll of gauze works well. “Haemostatic dressings” eg quik clot, don’t seem to make much difference.  It appears the pack needs to be absorbent probably because they absorb water out of the blood in the wound thereby increasing the concentration of […]


Disaster Medicine. Wing Commander Dr Paul Nealis

Be prepared. Be prepared for the unexpected, logistical challenges, politics and politicians, strange infections, psychological stress,  Aussie docs not recognising melioidosis and a mysterious man in a Hawaiian shirt … with a small fleet of Black Hawk helicopters. You need to be flexible, creative and psychologically tough. Military doctor Paul Nealis discusses disaster medicine in […]

mass cas

Mass Casualty and Hazardous Substances Management

  Key points   Declare an Mass Casualty Event -> telephonists automatically call in multiple staff from many departments Lock down the hospital Send triage nurses outside front door and ambulance door (with PPE if HAZSUB) with security and radio to triage people in or away from hospital Assign roles in ED ED staff to […]

Fast AF

Anaesthetising and shocking an 89-year-old

About once a year I get to cardiovert a nonagenarian.  There are a lot of good learning points from a case like this and I used a different anaesthetic from earlier posts (see Salvage Cardioversion of a Surgical Patient and Fast AF) The case This one was a sprightly 89-year-old (near enough to a nonagenraian) […]


Oxy morons. Avoid prescribing oxycodone

It has been interesting moon-lighting at another hospital to see how much oxycodone (common brands names: oxynorm and oxycontin) was being used professionally and recreationally. I was out with a friend who told me he had been given 1 1/2 oxycontin tabs by an acquaintance a while ago and had been high as a kite […]