Adelaide - City of Churches and Cricket
Adelaide was but an overnight stopover en-route to "The Ghan" train service. This city is famous for its churches and a love of cricket and for many years was home to its adopted favourite son, Australia's legendary Sir Don Bradman, a cricketer of whom the whole world still speaks in deferential hushed tones.
The new airport is simply gorgeous. Clean, open and spacious with a definite Scandinavian feel to it, there is ample use of panoramic glass windows and warm wood panelling. It is also only a stone's throw from a large IKEA store!
It was a beautiful warm summer's day when we arrived - a cobalt blue cloudless sky and the sun beating down on a parched dry land. There is something quintessentially 'Australian' about this. We respond to the dry air in our nostrils, the muted and pastel green, gold, brown, ochre, blue and purple of the landscape, the way the brightness of the sun almost stings our eyes and makes us squint, and the stillness and expanse of the 'Great Southern Land' in which our heartbeat is just a tiny portion of the pulsating liveliness which underpins everything in and upon it. It is as if once the sun touches the land, the spirit of the land is magnified and radiates back outwards, illuminating us all.
I have not been to Adelaide for many years, and my first impression of it is that it is a bit like a large country town. It still possesses many of its 'Colonial era' buildings, and wide open boulevards. It made me think of other cities with quaint charm, such as Hobart and Christchurch in New Zealand. The centre of the city is laid out in a grid, so it is impossible to get lost, surrounded by the unimaginatively named "North", "South", "East" and "West" Terraces.
I recall from the distant past that the iconic Rundle Mall was quiet and gentrified, with many small cafes and eateries. Now it is busy, noisy and commercialised, not unlike any other major shopping centre/strip anywhere else in Australia. One curious thing was that a movie theatre was nowhere to be seen.
The beautiful St Francis Xavier Church is in the centre of the city, with a sculpture memorial to Australia's only Saint, Mary McKillop, out the front. Inside it is cool, dimly lit and contemplative, with a beautiful rose window above the back gallery. With ceiling fans creating a gentle breeze, it was a welcome respite from the heat.
What to do about food? With an annoyingly delayed 2pm check-in at the hotel (Rydges on South Terrace) our group trudged what turned out to be a very long way in the heat into the city searching for something as simple as a sandwich and fruit drink for lunch. Eventually we stumbled across Gouger Street, heart of Adelaide's 'foodie precinct' and found a Subway. As one of the healthiest of fast food choices, the turkey, ham and salad roll ($8.95 for a 12 inch Sub for sharing) and 500mL Goulburn Valley orange juice with pulp ($3.70) was like manna from heaven and supplied some much-needed energy. On our way back to the hotel, we also stumbled across an intriguing-sounding restaurant called "British India", near the corner of Gouger and Morphett Streets. The original plan was to return here for dinner, but exhaustion got in the way! However, upon researching this restaurant on Urbanspoon, the reviews were almost universally good, so it sounds like one worth trying if you are looking for somewhere to eat in central Adelaide.
Since there was no breakfast included with our package, taking care of this was also another obstacle to overcome. It was too far to walk back to Gouger Street with a shuttle pick-up shortly after 10am, and the hotel breakfast was way too expensive - $25 Continental, $28 Cooked, so another plan had to be hatched. According to the hotel information brochure, there was an IGA in nearby Gilbert Street (they neglected to mention that this was a looong way along the street back towards the city!) so we trudged off again and eventually found it. The airconditioning was a welcome relief and spent a whole $8.47 on breakfast for the group - milk, yoghurt and canned fruit. On reviewing the invoice later, we also discovered that we had been charged $0.10 for a plastic bag. The cashier did not advise that there was a charge for bags. As a strong proponent of recycleable bags at home, I would not have willingly purchased a plastic bag in this instance. Whether this is a South Australian or IGA initiative, they have a duty to inform customers prior to charging them.
On our way back from the supermarket, we decided to check out the bistro in the nearby pub on the corner of Gilbert Street and West Terrace - the Elephant and Castle (reviewed separately) and enjoyed a tasty and cost-effective meal.
Saturday, January 26, 2013
Travelling on "The Ghan" - flying from Melbourne to Adelaide with Virgin Australia
This Virgin Australian flight was part of the overall package offered by Great Southern Rail for travel on "The Ghan" from Adelaide to Darwin.
Once we got past the recurring issue of my Velocity account name "Dr..." not agreeing with the booking name "Ms..." all went swimmingly. The nice Virgin customer service person who resolved the conflict over the telephone so I could proceed with my online check-in informed me that at long last they are taking steps to upgrade their booking system to accept titles other than "Mr/Ms/Miss".
The flight attendants were all helpful and good-humoured, and the aircraft was very comfortable. In its favour were leather seats with fully retractable arm-rests (so one could stretch out across an entire row of three seats if so fortunate to have them all vacant) with gaily coloured alternating red, purple and grey headrests. I can readily recall several painful experiences trying to sleep on international flights where the arm-rests would only lift up so far and you had to be a bit of a contortionist and sadist to attempt to stretch out in these circumstances.
Having packed my trusty thermos of coffee (a brilliant and now somewhat antique small Kathmandu open-necked thermos with a screw lid which has a secret compartment for a teabag etc), I was delighted to discover that Virgin are now offering complimentary tea, coffee and newspapers, served with a smile.
Last year I had to travel to Queensland for family reasons, and there weren't many flight options, but using my Velocity points and a small amount of cash I was able to obtain a bargain deal on a Virgin 'Premium Economy' seat up the front of the 'plane. This was a great experience - a large plush and comfy leather seat and complimentary food, drink, water and entertainment, not to mention attentive flight attendants! This section of the ‘plane has now morphed into “Business Class”, but if you get the opportunity, it is well worth trying as a pleasant alternative to regular economy.
Melbourne being one of the few major cities in the civilised world not to have a train link to the airport, it is always a vexed issue regarding the most efficient and cost-effective form of transport to and from the airport. Taxis are very expensive, and the Skybus service (http://skybus.com.au/) is very good ($28 return) but getting a connecting train home from Southern Cross Station in the city can be a problem if arriving in very late at night or in the early hours of the morning. Long-term parking at or near the airport is another option. A couple of years ago the prices went up dramatically for the long-term parking at the airport, rendering it less cost-effective, but over recent years a number of commercial operations have spring up which provide either outdoor or indoor parking for your vehicle and 24 hour shuttle buses to and from the airport.
Once we got past the recurring issue of my Velocity account name "Dr..." not agreeing with the booking name "Ms..." all went swimmingly. The nice Virgin customer service person who resolved the conflict over the telephone so I could proceed with my online check-in informed me that at long last they are taking steps to upgrade their booking system to accept titles other than "Mr/Ms/Miss".
The flight attendants were all helpful and good-humoured, and the aircraft was very comfortable. In its favour were leather seats with fully retractable arm-rests (so one could stretch out across an entire row of three seats if so fortunate to have them all vacant) with gaily coloured alternating red, purple and grey headrests. I can readily recall several painful experiences trying to sleep on international flights where the arm-rests would only lift up so far and you had to be a bit of a contortionist and sadist to attempt to stretch out in these circumstances.
Having packed my trusty thermos of coffee (a brilliant and now somewhat antique small Kathmandu open-necked thermos with a screw lid which has a secret compartment for a teabag etc), I was delighted to discover that Virgin are now offering complimentary tea, coffee and newspapers, served with a smile.
Last year I had to travel to Queensland for family reasons, and there weren't many flight options, but using my Velocity points and a small amount of cash I was able to obtain a bargain deal on a Virgin 'Premium Economy' seat up the front of the 'plane. This was a great experience - a large plush and comfy leather seat and complimentary food, drink, water and entertainment, not to mention attentive flight attendants! This section of the ‘plane has now morphed into “Business Class”, but if you get the opportunity, it is well worth trying as a pleasant alternative to regular economy.
Melbourne being one of the few major cities in the civilised world not to have a train link to the airport, it is always a vexed issue regarding the most efficient and cost-effective form of transport to and from the airport. Taxis are very expensive, and the Skybus service (http://skybus.com.au/) is very good ($28 return) but getting a connecting train home from Southern Cross Station in the city can be a problem if arriving in very late at night or in the early hours of the morning. Long-term parking at or near the airport is another option. A couple of years ago the prices went up dramatically for the long-term parking at the airport, rendering it less cost-effective, but over recent years a number of commercial operations have spring up which provide either outdoor or indoor parking for your vehicle and 24 hour shuttle buses to and from the airport.
A firm called Busy Beaver Airport Parking (http://www.busybeaverairportparking.com.au/) regularly places discount vouchers in letterbox drops, and I decided to make enquiries as a late-night arrival back into Melbourne was going to be problematic re suburban train connections. Their discount voucher was not applicable as a public holiday was included in the relevant period, but the regular price of $52 (outdoor) for five days was very good value and cheaper than Skybus for our travelling group.
Medical Book Review - Practical Management of Head and Neck Injury
Practical Management of Head and Neck Injury
Edited by Professor Jeffrey V Rosenfeld
Churchill Livingstone/Elsevier 2012
Paperback edition 500 pages
http://www.elsevierhealth.com.au/emergency-medicine/practical-management-of-head-and-neck-injury-paperback/9780729539562/
Put simply, this book is a fabulous resource which holds value for everyone from pre-hospital first responders in a remote location through medical to students, junior doctors and trainees to specialists. "The book adopts an evidence-based approach to the management of traumatic head and neck injury, supported by the latest research." It "captures the essence of the day-to-day management of head and neck injury by following all aspects of care through the patient's journey ..."
Its special features highlighted on the back cover are:
The layout of the book comprises:
Edited by Professor Jeffrey V Rosenfeld
Churchill Livingstone/Elsevier 2012
Paperback edition 500 pages
http://www.elsevierhealth.com.au/emergency-medicine/practical-management-of-head-and-neck-injury-paperback/9780729539562/
Put simply, this book is a fabulous resource which holds value for everyone from pre-hospital first responders in a remote location through medical to students, junior doctors and trainees to specialists. "The book adopts an evidence-based approach to the management of traumatic head and neck injury, supported by the latest research." It "captures the essence of the day-to-day management of head and neck injury by following all aspects of care through the patient's journey ..."
Its special features highlighted on the back cover are:
- The complete management of patients with head and neck trauma, from the accident scene through to rehabilitation;
- Safe, practical tips to assist the non-neurosurgoen in managing head injuries and preventing secondary brain injury - a major concern for emergency and pre-hospital medical personnel;
- All aspects of neck trauma covered, including the management of cervical spine injury;
- Detailed discussion of topics such as the classification of brain injury, concussion in sport, head injuries in children and the elderly, penetrating head injuries and the prognosis of head injury;
- The operative surgery of head and neck trauma outlined for the non-surgeon;
- Contributions from a wide range of specialists, both from Australia and overseas;
- Integration of neurosurgery with ear, nose and throat (ENT) surgery, maxillofacial surgery, ophthalmology and spinal orthopaedics; and
- Basic principles of relevant anatomy and pathophysiology, each covered in a separate chapter.
The layout of the book comprises:
- Contents
- Foreword
- Preface
- Acknowledgments
- Contributors and reviewers
- 1. Epidemiology
- 2. Anatomy of the head and neck
- 3. Pathophysiology of traumatic brain injury
- 4. Pre-hospital management
- 5. Emergency department management
- 6. Injury to the spine and spinal cord
- 7. Vascular injury
- 8. Operative surgery
- 9. Intensive care management of head injury
- 10. Ward care of the head-injured patient
- 11. Rehabilitation
- 12. Head injury in children
- 14. Head injury in sport
- 15. Penetrating head injury
- 16. Bleeding diathesis and anticoagulants
- 17. Neurotrauma in pregnancy
- 18. Brain death
- 19. Persistent vegetative and minimally responsive states following head injury
- 20. Prediction of outcome and the prognosis of head injury
- 21. Prevention of head injury and the role of trauma systems.
- Index
The illustrations are an excellent aid to understanding, and include tables, graphs, stylised and line drawings, anatomical drawings, CT and MRI scans, angiograms, pathology specimens, real-life 'action shots' including surgical instruments and processes, and reproductions of various guidelines and protocols. The authors have obviously gone to some effort to make this book a practical rather than theoretical resource.
As someone who has worked with Ski Patrol in remote locations as both a volunteer patroller and a medic and in small town rural emergency practice, I thought I would try approaching my review of this book from this perspective and look at its utility from the point of view of both a first responder and a remote emergency practitioner. Accordingly, the three chapters that I will specifically examine here are:
Chapter 4 opens with an explanation of the goals of pre-hospital emergency medical service (EMS) treatment for severe traumatic brain injury (TBI) and then proceeds with sound advice for bystanders immediately to call the EMS and to place an unconscious casualty in the left lateral position. However, things become a bit more murky thereafter. If respirations cease, the bystander is advised to give some expired air resuscitation in the supine position and cardiac arrest should be assumed and chest compressions commenced. However, this is at odds with the current Australian Resuscitation Council (ARC) Guidelines which are taught in first-aid courses that if someone is unconscious and not breathing normally, chest compressions should be commenced first, followed by breaths in the ratio of 30:2.
With reference to removing a motorcycle helmet, the importance of stabilising the cervical spine during this procedure could have been stressed, and perhaps even instructions provided (for instance, the American College of Surgeons has a nice PDF diagram with explanatory notes).
Under the "Paramedic Initial Assessment" the mnemonic "DRABC" is used. However, this has now been superseded in Basic Life Support by "DRSABC", where the "S" stands for "send for help". Even though some might argue that the paramedics "are the help", even for trained first responders, the "S" serves to remind them to reflect on whether they can manage the situation or need to call for further reinforcements.
There is a good discussion of potential dangers, but the text disappointingly then goes on to refer to the "AVPU" scale for assessing conscious state rather than the 'gold standard Glasgow Coma Scale (GCS). The GCS is taught to ski patrollers and certainly appears in the Ambulance Victoria CPGs (as part of the "Vital Signs Survey" which immediately follows the Primary Survey) and is of course used in Emergency Departments and can form a vital component of handover. Perhaps AVPU is appropriate as an instant assessment prior to completion of the Primary Survey, but most practitioners would probably prefer an accurate assessment of the GCS prior to determining whether to proceed with a Rapid Sequence Induction (RSI) and intubation as discussed in the next section. The GCS score forms part of the assessment in the Ambulance Victoria "Trauma Time Critical Guidelines". A pre-hospital GCS score is actually referred to later in the airway/breathing section and in the section on circulation, so it is a pity that its place in pre-hospital EMS management was not consistently considered in this chapter.
The advice about inserting an oropharygeal airway is confusing, and one would hope that clearing the airway of any debris that is present would occur prior to attempting to insert any type of airway. It is not mentioned that caution is indicated in inserting a nasopharyngeal airway in TBI where there is any suspicion of a base-of-skull fracture. There is also no reference to positioning of the head for optimal ventilation; nor to the possible modalities of mouth -to-mouth or mouth-to-mask in pre-hospital practice. My own feeling is that this section is rather clumsy and does not echo the clear and methodical approach that is used in Ski Patrol BLS training. Airway - inspect and clear if necessary. Breathing - look, listen and feel. Patrollers are permitted to make a short pulse check, but if the patient if not breathing normally, commence compressions and assisted ventilations after first favourably positioning the head. Only if ventilation is inadequate (even with a two-person technique) is the use of an airway adjunct then considered. Especially with a TBI, caution is required as triggering the gag reflex may contribute to vomiting and aspiration and an increase in intracranial pressure. With regard to ventilating the patient, if there is a significant mechanism of injury and spinal injury is suspected, special care must be taken with positioning of the head and neck and minimising movement. This is not mentioned at all.
The reference to the insertion of chest drains for decompressing a tension pneumothorax is somewhat alarming, as the Ambulance Victoria guidelines only refer to needle decompression, and specialist skills and equipment would be required for a drain.
Only at this point is fitting a cervical collar mentioned. Once again, instructions might be useful in terms of how to approach this and stabilisation of the head and neck during the procedure.
There is an extensive theoretical discussion about RSI in the field and whether this is of long-term benefit to the patient. (MICA paramedics in Victoria can intubate patients.) However, it was good to see discussed at the end of this section the issue of whether intubation should be undertaken without supplemental drugs. At this point airway stimulation possibly leading to vomiting and a rise in ICP is actually mentioned!
The section on circulation primarily discusses hypotension and fluids. It might have been useful to include some of the basics, such as expanding on the unreliability of the pulse check and whether standard first-aid measures such as elevating the feet are appropriate in TBI. In a remote or wilderness setting access to IV fluids may not be initially available. It was good to mention the points about control of haemorrhage.
I find it surprising that the author has not referred to the ARC Guidelines at all in this chapter, as they contain a wealth of information relating to management of a patient in the pre-hospital setting. They are the 'Bible' which forms the basis for the Ski Patrol Advanced Emergency Care Manual.
The "Additional initial procedures" and "Secondary Survey" contents are certainly not consistent with the Ambulance Victoria approach, which follows the Primary Survey with the "Vital Signs Survey" - GCS and assessment of perfusion state and respiratory state and pattern/mechanism of injury/medical condition - the purpose of which is to determine the time criticality to manage appropriately. The "Secondary Survey" covers a head to toe assessment (inspection, palpation, auscultation), pulse oximetry, monitor/ECG, temperature, EtCO2, blood glucose level and more detailed history. The combination of these three surveys allows the clinical problems to be identified. It is disappointing that a GCS assessment is only mentioned as part of the Secondary Survey here. Blood sugar is mentioned under a separate heading.
The author discusses the role of therapeutic hypothermia and concludes that it is not recommended in TBI patients outside the setting of a clinical trial. It might have been useful to provide some advice about the optimal management of hypothermic TBI patients in terms of preventing further heat loss and warming them as they make their way to definitive care.
The final section about transport discusses the role of specialised trauma centres and the efficacy of helicopter transport. One issue it does not raise is the possibility of transport delays in remote areas (not uncommon whilst awaiting evacuation from alpine locations) and monitoring and care of the patient (who may possibly deteriorate) whilst awaiting transport (or even arrival of the EMS). A short Summary and references are provided at the end of the chapter.
In summary, I found this chapter disappointing. It was disorganised and large chunks were more theoretical than practical, and the inconsistencies with Australian practices would be confusing for some people. However some of the discussion aspects were both interesting and useful. (It is noted that there is extensive information provided on both RSI and GCS in Chapter 5, "Emergency Department Management".)
Chapter 14 "Head injury in sport" is a much larger chapter and well laid-out and practical in emphasis. The chapter begins with a discussion about concussion and provides a useful 2001 consensus definition. The incidence section covers both American and Australian sports and helpfully mentions the factors that may affect the incidence of concussion in sports. The authors subsequently introduce the "Concussion in Sport Group" (CISG) and its consensus statements and assessment tools. This leads into an extensive section on "On-field assessment and game-day management", which is written in such a way as to be comprehensible by people outside the health professions (although it might be difficult to follow in places without having had any first-aid training), and it is stressed that such people have a vital role to play in the assessment and management of concussion. A copy of a 'pocket assessment card' (also available as an "app") and a long list of the symptoms of concussion are provided. Game-day management follows. There are a couple of references back to Chapter 4 "Pre-Hospital Management' regarding the "general rules of emergency management of head injury" (more succinctly summarised here than there) and the "general head-injury pathway" (which I could not find mentioned in Chapter 4, and there is certainly no flow diagram for a 'pathway'). This section suggests a number of relevant assessment tools and emphasises continued monitoring and follow-up. A note on impact seizures follows.
The section on "Post-game day concussion management" highlights the need for a complete brain recovery before return to play and provides a graduated return-to-play protocol. A couple of pages follow on different modalities of "Ancillary testing". At the conclusion of the chapter several assessment tools are reproduced together with some advice sheets.
Expanding on the "if in doubt, sit them out" them, the section on "Return to sport" includes a discussion on 'Modifiers' - factors which complicate recovery, and protective equipment and evidence for benefit. (This theme is taken up again at the end of the chapter in respect of "Return to sport, return to school, return to work".) There are three "Special situations" discussed in the following section - children, diffuse cerebral swelling and second-impact syndrome, and boxing. Although these discussions are more academic, they are still quite accessible. The paragraphs on boxing are particularly sobering and provide good background information concerning the consequences.
The penultimate section (before the succinct and pragmatic Summary) on "Prevention and education" provides some very useful information and practical advice. Two case studies (with discussion) are also included, the second one raising the issue of where does a GP go for advice on managing a patient whilst that person is waiting for an Outpatients appointment? Answer: continue monitoring and arrange a more timely assessment by someone experienced in concussion management. The corollary of this is that it is useful for GPs to have some idea of "who ya gonna call?" in the local area. (References are provided at the end of the chapter.)
I felt this was a terrific chapter, and it certainly has potential to be useful to all levels of health professionals.
Lest I exhaust the reader, I will not go into so much detail concerning Chapter 21, "Prevention of head injury and the role of trauma systems". It is a relatively short chapter (with Key Points and references at the end). The introduction concerning the categorisation of prevention activities as primary, secondary or tertiary and the use of Haddon's Matrix as a conceptual framework for "understanding the origins of injury problems and for identifying ways to address these problems" is interesting. A worked example of the Matrix is provided in Table 21.1. A section is devoted to each level of prevention - "Primary prevention: various measures", "Secondary prevention: trauma systems" and "Tertiary prevention: rehabilitation". This final section reminds the reader of the 'hidden costs' of TBI: "For every two patients who die of traumatic brain injuries, there are ten survivors with severe permanent disabilities".
The section on primary prevention concentrates on road traffic injuries, discussing the minimisation of exposure to high-risk scenarios, restraints, airbags and helmets (motorcycle and bicycle). Harking back to the two chapters examined above, I would have liked to see a wider discussion of the role of helmets including in sporting activities. Although their use is becoming more prevalent in the snowsports setting, some people still remain to be persuaded, and a textbook like this could play a powerful role in this struggle. The discussion on trauma systems, including the historical background, is really interesting. It also emphasises the importance of assessing the level of consciousness using the GCS as a modality of deciding the disposition of the patient. "Getting it right" in terms of where the patient is sent at first instance for definitive care is important, and this may be an issue in rural and remote areas with long waits for transport or accessibility issues e.g., bad weather. Sometimes ambulance dispatch may have a different view about time criticality to the people on the ground. Together with my colleagues at a Victorian alpine resort, I have experienced such a situation, where we told dispatch that we had a patient with a serious orthopaedic injury who needed to go by helicopter to Melbourne. A road crew was sent instead after several hours' delay. When they arrived and saw the patient they immediately concurred with our assessment and a helicopter was called for. By now it was night-time and the weather conditions had become difficult, but fortunately the road crew was able to drive the patient to a landing site lower down the mountain and met the helicopter there. I mention this story because of the issue of communication - for the trauma system to work effectively there must be good communication and trust in the assessment of the people in the field (as well as objective criteria such as vital signs and GCS). Perhaps as 'icing on the cake' it would have been appropriate to mention the importance of good communication and teamwork between different types of health professionals in the trauma setting. An emergency consultant once said to me that “trauma is a team sport”, and my own experience has shown this to be a truism. (This subject is addressed briefly in Chapter 5.)
In a book like this where different chapters are written by different people, there is bound to be some variation in style, and this is acknowledged by the editor in his Preface. Even to someone just flicking through the pages, it is immediately obvious the book contains a wealth of high-quality information and great care in its preparation. There is no doubt that many medical students and doctors find neuroscience a forbidding and inaccessible topic, and overall the editor and the authors are to be congratulated on producing a very practical and useful book which explains concepts which might otherwise be daunting in an accessible way.
Verdict: Recommended!
As someone who has worked with Ski Patrol in remote locations as both a volunteer patroller and a medic and in small town rural emergency practice, I thought I would try approaching my review of this book from this perspective and look at its utility from the point of view of both a first responder and a remote emergency practitioner. Accordingly, the three chapters that I will specifically examine here are:
- Chapter 4 - Pre-hospital management;
- Chapter 14 - Head injury in sport; and
- Chapter 21 - Prevention of head injury and the role of trauma systems.
With reference to removing a motorcycle helmet, the importance of stabilising the cervical spine during this procedure could have been stressed, and perhaps even instructions provided (for instance, the American College of Surgeons has a nice PDF diagram with explanatory notes).
Under the "Paramedic Initial Assessment" the mnemonic "DRABC" is used. However, this has now been superseded in Basic Life Support by "DRSABC", where the "S" stands for "send for help". Even though some might argue that the paramedics "are the help", even for trained first responders, the "S" serves to remind them to reflect on whether they can manage the situation or need to call for further reinforcements.
There is a good discussion of potential dangers, but the text disappointingly then goes on to refer to the "AVPU" scale for assessing conscious state rather than the 'gold standard Glasgow Coma Scale (GCS). The GCS is taught to ski patrollers and certainly appears in the Ambulance Victoria CPGs (as part of the "Vital Signs Survey" which immediately follows the Primary Survey) and is of course used in Emergency Departments and can form a vital component of handover. Perhaps AVPU is appropriate as an instant assessment prior to completion of the Primary Survey, but most practitioners would probably prefer an accurate assessment of the GCS prior to determining whether to proceed with a Rapid Sequence Induction (RSI) and intubation as discussed in the next section. The GCS score forms part of the assessment in the Ambulance Victoria "Trauma Time Critical Guidelines". A pre-hospital GCS score is actually referred to later in the airway/breathing section and in the section on circulation, so it is a pity that its place in pre-hospital EMS management was not consistently considered in this chapter.
The advice about inserting an oropharygeal airway is confusing, and one would hope that clearing the airway of any debris that is present would occur prior to attempting to insert any type of airway. It is not mentioned that caution is indicated in inserting a nasopharyngeal airway in TBI where there is any suspicion of a base-of-skull fracture. There is also no reference to positioning of the head for optimal ventilation; nor to the possible modalities of mouth -to-mouth or mouth-to-mask in pre-hospital practice. My own feeling is that this section is rather clumsy and does not echo the clear and methodical approach that is used in Ski Patrol BLS training. Airway - inspect and clear if necessary. Breathing - look, listen and feel. Patrollers are permitted to make a short pulse check, but if the patient if not breathing normally, commence compressions and assisted ventilations after first favourably positioning the head. Only if ventilation is inadequate (even with a two-person technique) is the use of an airway adjunct then considered. Especially with a TBI, caution is required as triggering the gag reflex may contribute to vomiting and aspiration and an increase in intracranial pressure. With regard to ventilating the patient, if there is a significant mechanism of injury and spinal injury is suspected, special care must be taken with positioning of the head and neck and minimising movement. This is not mentioned at all.
The reference to the insertion of chest drains for decompressing a tension pneumothorax is somewhat alarming, as the Ambulance Victoria guidelines only refer to needle decompression, and specialist skills and equipment would be required for a drain.
Only at this point is fitting a cervical collar mentioned. Once again, instructions might be useful in terms of how to approach this and stabilisation of the head and neck during the procedure.
There is an extensive theoretical discussion about RSI in the field and whether this is of long-term benefit to the patient. (MICA paramedics in Victoria can intubate patients.) However, it was good to see discussed at the end of this section the issue of whether intubation should be undertaken without supplemental drugs. At this point airway stimulation possibly leading to vomiting and a rise in ICP is actually mentioned!
The section on circulation primarily discusses hypotension and fluids. It might have been useful to include some of the basics, such as expanding on the unreliability of the pulse check and whether standard first-aid measures such as elevating the feet are appropriate in TBI. In a remote or wilderness setting access to IV fluids may not be initially available. It was good to mention the points about control of haemorrhage.
I find it surprising that the author has not referred to the ARC Guidelines at all in this chapter, as they contain a wealth of information relating to management of a patient in the pre-hospital setting. They are the 'Bible' which forms the basis for the Ski Patrol Advanced Emergency Care Manual.
The "Additional initial procedures" and "Secondary Survey" contents are certainly not consistent with the Ambulance Victoria approach, which follows the Primary Survey with the "Vital Signs Survey" - GCS and assessment of perfusion state and respiratory state and pattern/mechanism of injury/medical condition - the purpose of which is to determine the time criticality to manage appropriately. The "Secondary Survey" covers a head to toe assessment (inspection, palpation, auscultation), pulse oximetry, monitor/ECG, temperature, EtCO2, blood glucose level and more detailed history. The combination of these three surveys allows the clinical problems to be identified. It is disappointing that a GCS assessment is only mentioned as part of the Secondary Survey here. Blood sugar is mentioned under a separate heading.
The author discusses the role of therapeutic hypothermia and concludes that it is not recommended in TBI patients outside the setting of a clinical trial. It might have been useful to provide some advice about the optimal management of hypothermic TBI patients in terms of preventing further heat loss and warming them as they make their way to definitive care.
The final section about transport discusses the role of specialised trauma centres and the efficacy of helicopter transport. One issue it does not raise is the possibility of transport delays in remote areas (not uncommon whilst awaiting evacuation from alpine locations) and monitoring and care of the patient (who may possibly deteriorate) whilst awaiting transport (or even arrival of the EMS). A short Summary and references are provided at the end of the chapter.
In summary, I found this chapter disappointing. It was disorganised and large chunks were more theoretical than practical, and the inconsistencies with Australian practices would be confusing for some people. However some of the discussion aspects were both interesting and useful. (It is noted that there is extensive information provided on both RSI and GCS in Chapter 5, "Emergency Department Management".)
Chapter 14 "Head injury in sport" is a much larger chapter and well laid-out and practical in emphasis. The chapter begins with a discussion about concussion and provides a useful 2001 consensus definition. The incidence section covers both American and Australian sports and helpfully mentions the factors that may affect the incidence of concussion in sports. The authors subsequently introduce the "Concussion in Sport Group" (CISG) and its consensus statements and assessment tools. This leads into an extensive section on "On-field assessment and game-day management", which is written in such a way as to be comprehensible by people outside the health professions (although it might be difficult to follow in places without having had any first-aid training), and it is stressed that such people have a vital role to play in the assessment and management of concussion. A copy of a 'pocket assessment card' (also available as an "app") and a long list of the symptoms of concussion are provided. Game-day management follows. There are a couple of references back to Chapter 4 "Pre-Hospital Management' regarding the "general rules of emergency management of head injury" (more succinctly summarised here than there) and the "general head-injury pathway" (which I could not find mentioned in Chapter 4, and there is certainly no flow diagram for a 'pathway'). This section suggests a number of relevant assessment tools and emphasises continued monitoring and follow-up. A note on impact seizures follows.
The section on "Post-game day concussion management" highlights the need for a complete brain recovery before return to play and provides a graduated return-to-play protocol. A couple of pages follow on different modalities of "Ancillary testing". At the conclusion of the chapter several assessment tools are reproduced together with some advice sheets.
Expanding on the "if in doubt, sit them out" them, the section on "Return to sport" includes a discussion on 'Modifiers' - factors which complicate recovery, and protective equipment and evidence for benefit. (This theme is taken up again at the end of the chapter in respect of "Return to sport, return to school, return to work".) There are three "Special situations" discussed in the following section - children, diffuse cerebral swelling and second-impact syndrome, and boxing. Although these discussions are more academic, they are still quite accessible. The paragraphs on boxing are particularly sobering and provide good background information concerning the consequences.
The penultimate section (before the succinct and pragmatic Summary) on "Prevention and education" provides some very useful information and practical advice. Two case studies (with discussion) are also included, the second one raising the issue of where does a GP go for advice on managing a patient whilst that person is waiting for an Outpatients appointment? Answer: continue monitoring and arrange a more timely assessment by someone experienced in concussion management. The corollary of this is that it is useful for GPs to have some idea of "who ya gonna call?" in the local area. (References are provided at the end of the chapter.)
I felt this was a terrific chapter, and it certainly has potential to be useful to all levels of health professionals.
Lest I exhaust the reader, I will not go into so much detail concerning Chapter 21, "Prevention of head injury and the role of trauma systems". It is a relatively short chapter (with Key Points and references at the end). The introduction concerning the categorisation of prevention activities as primary, secondary or tertiary and the use of Haddon's Matrix as a conceptual framework for "understanding the origins of injury problems and for identifying ways to address these problems" is interesting. A worked example of the Matrix is provided in Table 21.1. A section is devoted to each level of prevention - "Primary prevention: various measures", "Secondary prevention: trauma systems" and "Tertiary prevention: rehabilitation". This final section reminds the reader of the 'hidden costs' of TBI: "For every two patients who die of traumatic brain injuries, there are ten survivors with severe permanent disabilities".
The section on primary prevention concentrates on road traffic injuries, discussing the minimisation of exposure to high-risk scenarios, restraints, airbags and helmets (motorcycle and bicycle). Harking back to the two chapters examined above, I would have liked to see a wider discussion of the role of helmets including in sporting activities. Although their use is becoming more prevalent in the snowsports setting, some people still remain to be persuaded, and a textbook like this could play a powerful role in this struggle. The discussion on trauma systems, including the historical background, is really interesting. It also emphasises the importance of assessing the level of consciousness using the GCS as a modality of deciding the disposition of the patient. "Getting it right" in terms of where the patient is sent at first instance for definitive care is important, and this may be an issue in rural and remote areas with long waits for transport or accessibility issues e.g., bad weather. Sometimes ambulance dispatch may have a different view about time criticality to the people on the ground. Together with my colleagues at a Victorian alpine resort, I have experienced such a situation, where we told dispatch that we had a patient with a serious orthopaedic injury who needed to go by helicopter to Melbourne. A road crew was sent instead after several hours' delay. When they arrived and saw the patient they immediately concurred with our assessment and a helicopter was called for. By now it was night-time and the weather conditions had become difficult, but fortunately the road crew was able to drive the patient to a landing site lower down the mountain and met the helicopter there. I mention this story because of the issue of communication - for the trauma system to work effectively there must be good communication and trust in the assessment of the people in the field (as well as objective criteria such as vital signs and GCS). Perhaps as 'icing on the cake' it would have been appropriate to mention the importance of good communication and teamwork between different types of health professionals in the trauma setting. An emergency consultant once said to me that “trauma is a team sport”, and my own experience has shown this to be a truism. (This subject is addressed briefly in Chapter 5.)
In a book like this where different chapters are written by different people, there is bound to be some variation in style, and this is acknowledged by the editor in his Preface. Even to someone just flicking through the pages, it is immediately obvious the book contains a wealth of high-quality information and great care in its preparation. There is no doubt that many medical students and doctors find neuroscience a forbidding and inaccessible topic, and overall the editor and the authors are to be congratulated on producing a very practical and useful book which explains concepts which might otherwise be daunting in an accessible way.
Verdict: Recommended!
Medical Book Review - Emergency Medicine MCQs
Emergency Medicine MCQs
by Waruna De Alwis and Yolande Weiner
Publisher: Churchill Livingstone/Elsevier
Paperback edition 2012 (440 pages)
http://www.elsevierhealth.com.au/clinical-general-medicine/emergency-medicine-mcqs-paperback/9780729541046/
Layout:
Part of the very great appeal of this book is that it is written for Australian conditions (by two FACEMs working at Logan Hospital in Queensland), and should be very helpful to those studying for the ACEM Fellowship exam as well as those working regularly in the area who wish to expand and consolidate their knowledge of emergency medicine.
by Waruna De Alwis and Yolande Weiner
Publisher: Churchill Livingstone/Elsevier
Paperback edition 2012 (440 pages)
http://www.elsevierhealth.com.au/clinical-general-medicine/emergency-medicine-mcqs-paperback/9780729541046/
Layout:
- Contents
- List of Authors and Contributors
- List of Reviewers
- Dedication
- Preface
- Acknowledgements
- Questions: Chapters 1-24
- Answers: Chapters 1-24
- Index
Part of the very great appeal of this book is that it is written for Australian conditions (by two FACEMs working at Logan Hospital in Queensland), and should be very helpful to those studying for the ACEM Fellowship exam as well as those working regularly in the area who wish to expand and consolidate their knowledge of emergency medicine.
The book "is structured to reflect the topics covered in the core curriculum of the Australasian College for emergency Medicine fellowship program" and "contains evidence-based, clinically relevant and practical multiple choice questions in adult and paediatric emergency medicine". The contents have drawn upon the knowledge and experience of expert authors in addition to textbooks and peer-reviewed journals. It is aimed not only at exam candidates but also at being a useful resource for everyday clinical practice and improving both knowledge and critical thinking skills.
Additional timed exam papers and quizzes are available in "Practice Exams in Emergency Medicine" for iOS devices and Android.
The topics covered in the Chapters are very comprehensive (as per the ACEM curriculum) and include:
Starting to look through the book was a bit like "being a kid in a candy store" as there were many areas I was interested in exploring to see how my existing knowledge 'stacks up'.
It is obviously not possible to review every single question and answer, so I will just look at a selection to try to give a flavour of the level of difficulty and the depth of the information provided in the answers.
In Chapter 1 on "Resuscitation", there are thirty-two questions relating to adult resuscitation and eighteen relating to paediatric resuscitation. These are fairly wide-ranging, (in adults) covering topics like CPR protocols, ventilatory support, defibrillation and pacing, hypothermia, lactic acidosis and septic shock, vasoactive substances, fluids, thoracotomy and echocardiography. I have to admit that I found some of these questions challenging (I'm not going to say how many I got right on the first pass!) and some of them I simply didn't have detailed enough knowledge even to make an 'educated guess'. However, the beauty of the answers is that they not only explain which is the correct answer (and why) but also why the other answers are incorrect.
I commend the authors on their use of terminology in the questions. It is very clear which alternative the reader is being asked to indentify e.g., "which ONE of the following statements is TRUE/INCORRECT" or "which ONE of the following is NOT ...". I think all medical students hate questions like "Choose the MOST CORRECT/LEAST CORRECT answer from the alternatives below". Some of the questions stray a little in this direction, such as "Which ONE of the following patients will MOST likely benefit ..." or "which ONE of the following is the MOST appropriate answer?" but it seems that the intention here is to tease out critical thinking rather than present a gradation of fiendishly difficult alternatives.
I have chosen one (shorter) example of a questions and answer from this chapter (which incidentally I did get right!):
27. Regarding the use of hypertonic saline in traumatic brain injury (TBI), which ONE of the following statements is true?
A. It reliably decreases intracranial pressure and significantly improves cerebral blood flow.
B. It is as effective as mannitol when osmotherapy is indicated.
C. There is good evidence showing an outcome benefit in TBI.
D. It is the preferred crystalloid if severe TBI occurs with hypotension.
27. Answer: B
Hypertonic saline as been shown to reliably decrease ICP in patients with TBI (LOE II) and it is at least as effective as mannitol. However, no studies so far have demonstrated improved cerebral blood flow; neither is there good evidence showing an outcome benefit. Despite the potential benefits in reducing ICP in patients with TBI, there is currently no evidence to recommend hypertonic saline over isotonic saline for fluid resuscitation and restoration of the intravascular volume (footnote 40).
References are supplied at the end of each chapter of Answers, and it is good to see that the authors are also supplying the Level of Evidence for propositions were relevant.
Next I thought I would move on to Chapter 12 "Emergency Anaesthesia and Pain Management", which I also hoped I would know something about already! There are twenty questions, relating to RSI, medications, local anaesthetics, nerve blocks, opiods, procedural sedation and pain management (these cover both adults and children).
These questions require quite a bit of detailed knowledge, so I think people who are not regularly dealing with the content on a regular basis will find them quite challenging. However, the answers are very educative.
Here is an example from this chapter.
4. The laryngeal mask airway (LMA) is a successful rescue device in emergency airway management. Which ONE of the following statements is TRUE regarding the LMA?
A. Positioning of the patient into the 'sniffing' position is essential.
B. It is a useful alternative to an ETT for establishing a definitive airway.
C. Cricoid pressure almost always impedes insertion of an LMA.
D. The device should be held firmly in place during inflation to allow the LMA to seat properly.
4. Answer: C
The LMA is a useful alternative to endotracheal intubation when an advanced airway is required but it is not a definitive airway and doesn't protect the patient from aspiration. Positioning of the patient into the 'sniffing' position is not essential but it is preferable. The LMA should not be held while the cuff is being inflated to allow the LMA to seat properly. The LMA tube on average will move out of the mouth approximately 0.7% during inflation. The LMA can potentially be placed too deeply if the tube is held in place during inflation and not allowed to rise slightly. (Footnotes 10-12.)
This answer demonstrates nicely how the authors have in many answers highlighted particularly salient points.
Additional timed exam papers and quizzes are available in "Practice Exams in Emergency Medicine" for iOS devices and Android.
The topics covered in the Chapters are very comprehensive (as per the ACEM curriculum) and include:
- Resuscitation
- Cardiovascular emergencies
- Respiratory emergencies
- Neurological and neurospinal emergencies
- Endocrine emergencies
- Gastrointestinal emergencies
- Renal emergencies
- Haematological and oncological emergencies
- Infectious diseases
- Dermatological emergencies
- Electrolyte and acid-base disorders
- Emergency anaesthesia and pain management
- Trauma and burns
- Orthopaedic emergencies
- Surgical emergencies
- Eye, ENT and dental emergencies
- Urological emergencies
- Obstetric and gynaecological emergencies
- Toxicology and toxinology
- Environmental emergencies
- Psychiatric emergencies
- Paediatric emergencies
- Disaster management
- ED management and medicolegal issues.
Starting to look through the book was a bit like "being a kid in a candy store" as there were many areas I was interested in exploring to see how my existing knowledge 'stacks up'.
It is obviously not possible to review every single question and answer, so I will just look at a selection to try to give a flavour of the level of difficulty and the depth of the information provided in the answers.
In Chapter 1 on "Resuscitation", there are thirty-two questions relating to adult resuscitation and eighteen relating to paediatric resuscitation. These are fairly wide-ranging, (in adults) covering topics like CPR protocols, ventilatory support, defibrillation and pacing, hypothermia, lactic acidosis and septic shock, vasoactive substances, fluids, thoracotomy and echocardiography. I have to admit that I found some of these questions challenging (I'm not going to say how many I got right on the first pass!) and some of them I simply didn't have detailed enough knowledge even to make an 'educated guess'. However, the beauty of the answers is that they not only explain which is the correct answer (and why) but also why the other answers are incorrect.
I commend the authors on their use of terminology in the questions. It is very clear which alternative the reader is being asked to indentify e.g., "which ONE of the following statements is TRUE/INCORRECT" or "which ONE of the following is NOT ...". I think all medical students hate questions like "Choose the MOST CORRECT/LEAST CORRECT answer from the alternatives below". Some of the questions stray a little in this direction, such as "Which ONE of the following patients will MOST likely benefit ..." or "which ONE of the following is the MOST appropriate answer?" but it seems that the intention here is to tease out critical thinking rather than present a gradation of fiendishly difficult alternatives.
I have chosen one (shorter) example of a questions and answer from this chapter (which incidentally I did get right!):
27. Regarding the use of hypertonic saline in traumatic brain injury (TBI), which ONE of the following statements is true?
A. It reliably decreases intracranial pressure and significantly improves cerebral blood flow.
B. It is as effective as mannitol when osmotherapy is indicated.
C. There is good evidence showing an outcome benefit in TBI.
D. It is the preferred crystalloid if severe TBI occurs with hypotension.
27. Answer: B
Hypertonic saline as been shown to reliably decrease ICP in patients with TBI (LOE II) and it is at least as effective as mannitol. However, no studies so far have demonstrated improved cerebral blood flow; neither is there good evidence showing an outcome benefit. Despite the potential benefits in reducing ICP in patients with TBI, there is currently no evidence to recommend hypertonic saline over isotonic saline for fluid resuscitation and restoration of the intravascular volume (footnote 40).
References are supplied at the end of each chapter of Answers, and it is good to see that the authors are also supplying the Level of Evidence for propositions were relevant.
Next I thought I would move on to Chapter 12 "Emergency Anaesthesia and Pain Management", which I also hoped I would know something about already! There are twenty questions, relating to RSI, medications, local anaesthetics, nerve blocks, opiods, procedural sedation and pain management (these cover both adults and children).
These questions require quite a bit of detailed knowledge, so I think people who are not regularly dealing with the content on a regular basis will find them quite challenging. However, the answers are very educative.
Here is an example from this chapter.
4. The laryngeal mask airway (LMA) is a successful rescue device in emergency airway management. Which ONE of the following statements is TRUE regarding the LMA?
A. Positioning of the patient into the 'sniffing' position is essential.
B. It is a useful alternative to an ETT for establishing a definitive airway.
C. Cricoid pressure almost always impedes insertion of an LMA.
D. The device should be held firmly in place during inflation to allow the LMA to seat properly.
4. Answer: C
The LMA is a useful alternative to endotracheal intubation when an advanced airway is required but it is not a definitive airway and doesn't protect the patient from aspiration. Positioning of the patient into the 'sniffing' position is not essential but it is preferable. The LMA should not be held while the cuff is being inflated to allow the LMA to seat properly. The LMA tube on average will move out of the mouth approximately 0.7% during inflation. The LMA can potentially be placed too deeply if the tube is held in place during inflation and not allowed to rise slightly. (Footnotes 10-12.)
This answer demonstrates nicely how the authors have in many answers highlighted particularly salient points.
By now I was realising that perhaps there is one small criticism in that there is no colour-coding of the chapters, and if you are just flicking through the book you have to look at the small print at the bottom of the pages to locate the chapter that you are looking for.
For my last example, I decided to have a look at a chapter that perhaps a lot of people might gloss over, but having done a post-graduate degree in this area I was interested to test my knowledge. Chapter 23 deals with "Disaster Management". In the relevant literature, it is recommended that all health professionals should know something about this area, but this rarely occurs in practice. All the American emergency medicine textbooks I have seen have splendid chapters on this topic. All credit to the authors for incuding it in their book and bringing this topic to the attention of a wider audience.
There are only ten questions. Once again, fairly detailed knowledge is required in order to answer them correctly.
9. Regarding a patient experiencing a significant radiation exposure, which ONE of the following statements is TRUE?
A. Patients developing symptoms secondary to gamma irradiation pose an ongoing risk to healthcare staff.
B. Bone marrow suppression following a serious exposure develops over 3-5 days.
C. Patients developing gastrointestinal symptoms can be expected to recover over 6-8 weeks.
D. Potassium iodide blocks the uptake of radioactive material if ingested in the first few hours following exposure.
9. Answer: D
In the event of a nuclear accident, radioactive iodine might be released into the environment. Potassium iodate tablets block the uptake of radioactive iodine by the thyroid gland, therefore reducing the risk of developing thyroid cancer. Irradiated patients are not radioactive, and so do not pose a risk to staff. Patients exposed to particulate radioactive material - such as following an explosion - may still have radioactive material on their person, and so should be considered as requiring decontamination until declared clear by a radiation safety officer. Haemopoetic syndrome - due to bone marrow suppression - displays developing symptoms of bleeding, depressed white cell count (WCC) resulting in impaired immune response and fatigue by 3 weeks post exposure. Treatment is supportive. Gastrointestinal symptoms of vomiting, bloody diarrhoea and ileus denote an exposure of >2-10 Gy, and result in 50% mortality due to renal, hepatic and pulmonary injuries. (Footnote 5.)
There is a small inconsistency between the question and answer - the question refers to "potassium iodide" whilst the answer refers to "potassium iodate".
The answers in this chapter are a good example of how the authors provide helpful mnemonics to assist memory and recall.
For FACEM candidates this book will no doubt be very useful in testing out the limits of knowledge and identifying weaknesses whilst also providing the means to remedy these theoretical gaps.
If you are not a FACEM candidate, this book is probably best approached with humility and an open mind and willingness to learn. If you look at it in those terms, it is a terrific resource that will help you to take your practice of emergency medicine to a higher level. It is a salient reminder that in the practice of medicine you should never be too cocky or complacent about your level of knowledge and the capacity for improvement.
Verdict: Recommended!
For my last example, I decided to have a look at a chapter that perhaps a lot of people might gloss over, but having done a post-graduate degree in this area I was interested to test my knowledge. Chapter 23 deals with "Disaster Management". In the relevant literature, it is recommended that all health professionals should know something about this area, but this rarely occurs in practice. All the American emergency medicine textbooks I have seen have splendid chapters on this topic. All credit to the authors for incuding it in their book and bringing this topic to the attention of a wider audience.
There are only ten questions. Once again, fairly detailed knowledge is required in order to answer them correctly.
9. Regarding a patient experiencing a significant radiation exposure, which ONE of the following statements is TRUE?
A. Patients developing symptoms secondary to gamma irradiation pose an ongoing risk to healthcare staff.
B. Bone marrow suppression following a serious exposure develops over 3-5 days.
C. Patients developing gastrointestinal symptoms can be expected to recover over 6-8 weeks.
D. Potassium iodide blocks the uptake of radioactive material if ingested in the first few hours following exposure.
9. Answer: D
In the event of a nuclear accident, radioactive iodine might be released into the environment. Potassium iodate tablets block the uptake of radioactive iodine by the thyroid gland, therefore reducing the risk of developing thyroid cancer. Irradiated patients are not radioactive, and so do not pose a risk to staff. Patients exposed to particulate radioactive material - such as following an explosion - may still have radioactive material on their person, and so should be considered as requiring decontamination until declared clear by a radiation safety officer. Haemopoetic syndrome - due to bone marrow suppression - displays developing symptoms of bleeding, depressed white cell count (WCC) resulting in impaired immune response and fatigue by 3 weeks post exposure. Treatment is supportive. Gastrointestinal symptoms of vomiting, bloody diarrhoea and ileus denote an exposure of >2-10 Gy, and result in 50% mortality due to renal, hepatic and pulmonary injuries. (Footnote 5.)
There is a small inconsistency between the question and answer - the question refers to "potassium iodide" whilst the answer refers to "potassium iodate".
The answers in this chapter are a good example of how the authors provide helpful mnemonics to assist memory and recall.
For FACEM candidates this book will no doubt be very useful in testing out the limits of knowledge and identifying weaknesses whilst also providing the means to remedy these theoretical gaps.
If you are not a FACEM candidate, this book is probably best approached with humility and an open mind and willingness to learn. If you look at it in those terms, it is a terrific resource that will help you to take your practice of emergency medicine to a higher level. It is a salient reminder that in the practice of medicine you should never be too cocky or complacent about your level of knowledge and the capacity for improvement.
Verdict: Recommended!
Dining in Style - The Queen Adelaide Restaurant on "The Ghan" Transcontinental Train (Day 3)
Tuesday 1 January 2013
Breakfast (0630 - 0830)
The menu was basically the same as yesterday, with juice, tea or coffee, a fruit-based dish or cereal, a main dish and toast.
The Eggs Florentine was in contrast excellent. This was made up with a muffin base, baby spinach, smoked salmon, poached eggs and bernaise sauce.
Another attractive looking alternative involved blueberries in syrup, fruit bread and double cream.
Lunch (13:00)
This was very similar to lunch on the first day, beginning with individual damper rolls, but this time accompanied by pepperberry butter and Davidson plum chilli preserve. The plum preserve had a delicious tang to it.
Continuing on with the fish theme, I selected as a main course the crispy skin Regatta Point Atlantic Salmon. This was served with asparagus spears, spiced watermelon cubes, cucumber and coriander salsa and fresh lime. The fish was beautifully cooked and the accompaniments were fresh and tasty. The watermelon really worked as part of the dish.
For dessert I did wonder if I should try the pannacotta, but decided to try the Lemon Meringue tart for a second time. It was again served with a mint leaf on top and a sweet and rich wild berry sauce containing redcurrants, raspberries and blueberries. The tangy lemon curd was tangy and slightly runny. There seemed to be some shredded coconut in the dish as well. The meringue was light and fluffy and the pastry was a good consistency. I felt that the dish was better the second time around - very enjoyable as a refreshing little dessert.
The meal was rounded off with a good strong full-bodied and cleansing cup of coffee with a pleasing after-taste. This was the best coffee that I had tasted for the whole journey.
Breakfast (0630 - 0830)
The menu was basically the same as yesterday, with juice, tea or coffee, a fruit-based dish or cereal, a main dish and toast.
The "Tropical Fruit" mixture - honeydew melon with native currants and a vinegarette dressing was rather disappointing. Just the melon on its own was rather monotonous and the currants were quite hard, with large stones in the centre.
The Eggs Florentine was in contrast excellent. This was made up with a muffin base, baby spinach, smoked salmon, poached eggs and bernaise sauce.
Another attractive looking alternative involved blueberries in syrup, fruit bread and double cream.
Lunch (13:00)
This was very similar to lunch on the first day, beginning with individual damper rolls, but this time accompanied by pepperberry butter and Davidson plum chilli preserve. The plum preserve had a delicious tang to it.
Continuing on with the fish theme, I selected as a main course the crispy skin Regatta Point Atlantic Salmon. This was served with asparagus spears, spiced watermelon cubes, cucumber and coriander salsa and fresh lime. The fish was beautifully cooked and the accompaniments were fresh and tasty. The watermelon really worked as part of the dish.
For dessert I did wonder if I should try the pannacotta, but decided to try the Lemon Meringue tart for a second time. It was again served with a mint leaf on top and a sweet and rich wild berry sauce containing redcurrants, raspberries and blueberries. The tangy lemon curd was tangy and slightly runny. There seemed to be some shredded coconut in the dish as well. The meringue was light and fluffy and the pastry was a good consistency. I felt that the dish was better the second time around - very enjoyable as a refreshing little dessert.
The meal was rounded off with a good strong full-bodied and cleansing cup of coffee with a pleasing after-taste. This was the best coffee that I had tasted for the whole journey.
Dining in Style - The Queen Adelaide Restaurant on "The Ghan" Transcontinental Train (Day 2)
Monday 31 December 2012
Brunch (mid-morning)
This began with a glass of fruit juice, followed by a fruit-based starter (or cereal) and then a wide choice of main meals, toast with accompaniments, tea or coffee.
The Wild Peach and Vanilla Parfait was lovely, consisting of succulent and sweet semi-stewed fruit with passionfuit, vanilla yoghurt, sliced almonds, hazlenuts and topped with a mint leaf.
The Full Breakfast was fairly traditional but not an overly large serving. It contained a slice of bacon, a small country sausage, half a grilled tomato, one champignon and a choice of eggs (poached, fried, scrambled).
There was a selection of toasted breads and toppings - butter or Beerenberg marmalade, honey, apricot and strawberry jams.
All very pleasant, but whether it was quite enough to tide us over until dinner remained to be seen.
Dinner (19:15)
The menu choices were exactly the same as the previous evening. The only difference was that instead of broccoli, chopped cooked red cabbage was served with the main meals.
I decided to try a different entree, and ordered the Haloumi Grilled Mushroom. This was a combination of a large brown mushroom, basil, sun-blushed tomato (still fairly soft), haloumi cheese, greens, caramellised bush tomatoes and balsamic syrup and a kalamata olive crumble. The mushroom was pretty bland and the crumble was dry. The tomato was nice and sweet but the sauce was quite acidic. Overall I didn't find the dish very appetising.
At home I am not a big meat eater, and after the past few days I was looking forward to something a bit lighter so turned to fish, which is probably my favourite form of protein. The Grilled Saltwater Barramundi consisted of a small piece of filleted barramundi with crispy cracked peppercorn coated skin on top. It was delightfully moist, flaky and tasty and could not have been cooked any better. The ubiquitous pancetta made another appearance on top of this dish. The fresh leaves of baby spinach were accompanied by a bland and disappointing cauliflower and horseradish puree and an interesting salty mixture of citrus, caviar and lemon oil.
I did contemplate having the apple tart for dessert this time, but was not persuaded that it looked appetising enough to forsake the chocolate pudding for dessert. This was still excellent on a second tasting, and the presence of the dried fruit and berries inside the cake really adds depth to the flavour.
Brunch (mid-morning)
This began with a glass of fruit juice, followed by a fruit-based starter (or cereal) and then a wide choice of main meals, toast with accompaniments, tea or coffee.
The Wild Peach and Vanilla Parfait was lovely, consisting of succulent and sweet semi-stewed fruit with passionfuit, vanilla yoghurt, sliced almonds, hazlenuts and topped with a mint leaf.
The Full Breakfast was fairly traditional but not an overly large serving. It contained a slice of bacon, a small country sausage, half a grilled tomato, one champignon and a choice of eggs (poached, fried, scrambled).
There was a selection of toasted breads and toppings - butter or Beerenberg marmalade, honey, apricot and strawberry jams.
All very pleasant, but whether it was quite enough to tide us over until dinner remained to be seen.
Dinner (19:15)
The menu choices were exactly the same as the previous evening. The only difference was that instead of broccoli, chopped cooked red cabbage was served with the main meals.
I decided to try a different entree, and ordered the Haloumi Grilled Mushroom. This was a combination of a large brown mushroom, basil, sun-blushed tomato (still fairly soft), haloumi cheese, greens, caramellised bush tomatoes and balsamic syrup and a kalamata olive crumble. The mushroom was pretty bland and the crumble was dry. The tomato was nice and sweet but the sauce was quite acidic. Overall I didn't find the dish very appetising.
I did contemplate having the apple tart for dessert this time, but was not persuaded that it looked appetising enough to forsake the chocolate pudding for dessert. This was still excellent on a second tasting, and the presence of the dried fruit and berries inside the cake really adds depth to the flavour.
That the kitchen is consistently able to turn out such a high standard of food in challenging circumstances is quite amazing, but I cannot help feeling that some of the dishes have been 'over-thought', with too many competing flavours (at times resulting in some "weird food" aspects), and there is only so much pancetta that you wish to see featuring as a component of menu choices. It would also be good to see a greater emphasis on vegetables as a balanced part of the main dishes as opposed to 'meat and potatoes', and perhaps some Asian-inspired dishes as this is such a significant part of Australian food culture. That said, it would not be appropriate to complain too much, as the restaurant team has done an excellent job despite the constraints and consistently demonstrated exemplary service.
Tuesday, January 8, 2013
Dining in Style - The Queen Adelaide Restaurant on "The Ghan" Transcontinental Train (Day 1)
Lunch (at 14:45!)
This is a dining experience not unlike the marvellous Colonial Tramcar Restaurant in Melbourne.
Patrons are seated in bays of four people, so for groups of less than four chances are that you will be making pleasant conversation with strangers, so have your 'small talk' ready!
For starters a plate of individual damper rolls with olive oil and spices was placed on the table and everyone was provided with a glass of water. (Other beverages are available at a cost.)
There were four mains to choose from (steak, salmon, chicken and goats cheese) and three desserts (lemon meringue tart, pannacotta or fruit). Service was very prompt, but no choice was offered with regard to the cooking of the steak, which universally arrived 'well done'.
The Angus Beef Medallions were served with some potato mash (sweetened by the addition of small pieces of caramellised onion), a tangy tomato chutney, a rich jus and a piece of bacon and a sprig of rosemary atop the steak.
Coffee and tea followed. This was a very pleasant meal, especially considering the limitations of the context.
Dinner
(19:15)
This was a three-course affair. For entree there was a choice of minestrone soup, blue swimmer crab and mushrooms with haloumi cheese.
The main course options consisted of beef cheek, lamb, pork, kangaroo, fish and vegetarian lasagne. For dessert the options were cheese, chocolate berry cake and apple tart.
The macerated blue swimmer crab was served on a piece of sourdough bread and accompanied by some leafy greens, guacamole, cucumber and thinly sliced pickled ginger.
In some ways it is a little unsettling to think about eating one of our national emblems A.K.A. the dearly beloved "Skippy the Bush Kangaroo" of childhood days, but it also seemed churlish to pass up the opportunity to try some unique Australian cuisine which was fully paid for as part of the package.
I must digress and tell the story of the brush tailed possum, protected in Australia but reviled in New Zealand as a toxic import. Anyone who has ever had a possum in their roof knows just how annoying and ornery these fluffy little critters can be, but woe betide you if you should set out to harm them in any way. It is a completely different story in New Zealand. On tour of the South Island several years back, I saw all manner of clothing items made out of possum fur (apparently gloves and socks are ever so soft and warm!) and on a tour was caused to visit Pete's Possum Shop, which sells all manner of possum paraphernalia, including possum pies. Yes, dear reader, in the interests of scientific curiosity, I consumed a possum pie. The meat was a bit like a greyish combination of chicken and lamb, but quite palatable. It is difficult to go past a nice old-fashioned pie with meat, gravy and melt-in-the mouth pastry. Oh, the irony of it! In Australia one might be jailed for making and eating such a pie, but in NZ it is encouraged!
Back to Skippy ... Two generous chunks of Nullabor Plains Kangaroo loin mignon were seared on the outside (served 'medium') wrapped in somewhat fatty pancetta and served with 'broken potatoes' (skin on), spiced quandong sauce and some fresh green broccoli. The pieces of kangaroo were a little tough and stringy in parts, and the dish would have benefited from being able to use a steak knife rather than an ordinary blunt knife. However, the majority of the meat was of a good consistency. The quandong (native berry) sauce was quite delicious.
The highlight of the meal was the Belgian Chocolate Muntries Pudding. This was presented as a warm flourless chocolate cake containing dried fruit, berries and streaks of chocolate ganache and a quenelle of double cream. The cake was light, fluffy and very yummy and the juicy berries combined well with the chocolate.
Once again water, tea and coffee were made available. Out the window to the west a beautiful sunset gradually evolved, with the golden sun shining through streaks of cirrus clouds low to the horizon and deepening hues of pink and purple.
Monday, January 7, 2013
Fresh off the boat - Chip 'N' Fish, Darwin
Kalbarri Shopping Centre,
69 Mitchell St ,
Darwin City, NT 0800
Darwin City, NT 0800
This Fish and Chip shop in the foodie district around Mitchell Street in central Darwin is a tiny 'hole in the wall' food outlet that prides itself on serving fresh seafood caught locally. There was an initial mix-up with the order as the cashier did not seem to understand what was being asked for, and the order had to be re-done, but things looked up from there.
The Seafood Basket ($16) contained some pieces of shark, two prawns, one scallop, one seafood stick, three calamari rings and a small serve of chips. All the seafood was cooked in a light and fluffy golden batter and was moist and flavoursome. The chips were a bit disappointing in terms of being slightly over-cooked and the size of the serve. However, the proprietors cannot be faulted in terms of cheerfully correcting the order and the quality of the food.
Verdict: Recommended.
A mighty good feast - Elephant & Castle Hotel, Adelaide
The bistro had a good variety of food at reasonable prices, and there was also a fairly extensive menu in the bar (at cheaper prices). Due to exhaustion from the aforementioned several hours of wandering the streets in the heat, eating here seemed like the easiest option. Keeping up the turkey and ham Christmas theme, the menu incuded roast turkey, ham and vegetables (and bread rolls) for $11.50 (and a lemon, lime and bitters for $3.50).
This was a lovely unpretentious meal. Visually attractive, it included a thick slice of turkey, several slices of ham, small potatoes roasted in their skins, a piece of roast pumpkin, a piece of parsnip and some sliced zucchini. This was accompanied by a rich (not too salty) gravy and a magnificent intense buttery sage stuffing. The large-leaf parsley garnish was surprisingly flavoursome.
Being in the bar area with a TAB and race commentary down the other end, the ambience was perhaps a little lacking, but the noise level wasn't too bad, and the service was friendly and helpful (even extending to some extra bread rolls). A big tick for tasty quality food at a very reasonable price.
Friday, January 4, 2013
It's just not Cricket!
For old-fashioned cricket lovers, it can be a cause of frustration that many Australian professional cricketers "throw the ball away" almost immediately after taking a catch. In some instances the ball is thrown away so rapidly that it would be possible to question whether the catch was actually taken. In addition to the rapid disposal, the ball often just 'falls to earth', risking damage, rather than being thrown to another player or the Umpire.
It is interesting that the same behaviour is not demonstrated by many international cricketers, who demonstrate greater respect for the ball by hanging on to it when taking a catch.
I am reliably informed that young cricketers used to be taught that it was best practice to protect and look after the ball and "keep the shine on it", especially as teams normally had to pay for their own balls.
Surely this cavalier behaviour is not setting a good example for our young cricketers and is sending the wrong message about respect for and stewardship of equipment. Perhaps in this instance we could learn a lesson from cricketers representing developing countries.
It is interesting that the same behaviour is not demonstrated by many international cricketers, who demonstrate greater respect for the ball by hanging on to it when taking a catch.
I am reliably informed that young cricketers used to be taught that it was best practice to protect and look after the ball and "keep the shine on it", especially as teams normally had to pay for their own balls.
Surely this cavalier behaviour is not setting a good example for our young cricketers and is sending the wrong message about respect for and stewardship of equipment. Perhaps in this instance we could learn a lesson from cricketers representing developing countries.
Fabulous Friday Fish and Chips in Northcote
Fish & Chips
Take Away FoodMilk Bar
62 Victoria Road, Northcote 3070
Tel: (03) 9481 3593
It being the holiday season, the normal fish and chippery is closed, but fortunately there is a reliable stand-by locally.
This shop has a milk bar in the front section and take-away food at the back. The proprietors also sell some small home-made Asian food items.
Blue grenadier (battered) $4.80
Potato cakes $0.80
Crumbed calamari rings (pre-formed) $0.80
Minimum chips $3.00
It was a generously sized moist and succulent piece of fish, and the potato cakes and chips were crispy on the outside and soft on the inside. All the batter was a lovely golden colour and there was no sense of oiliness. The calamari rings were also nicely cooked and tasty. The serve of chips was big enough to share.
The fish and chips are consistently good and the service prompt, polite and friendly.
Verdict: Recommended
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