Joe-Anthony Rotella

The role of short courses in Australasian emergency medicine training

For the purposes of this article, short courses are defined as courseworkbased training opportunities, of less than 2 week’s duration, delivered independently of hospital-based clinical teaching programmes. A growing number are available to emergency medicine (EM) clinicians and cover a variety of areas including trauma, resuscitation, ultrasound, paediatric emergencies and research methods. A sample of popular courses is provided in Box 1. The next edition of the Trainee Focus section will consider the role and value of longer, universitybased degree programmes focussed on EM. As scientific knowledge and trainee numbers in EM expand, demand for short courses is likely to grow. Other potential drivers of attendance include future increases in professional development (PD) allowances, and more rigourous safety and quality standards in relation to life support skills and training. The trend towards subspecialisation in EM might also precipitate new and expanded courses in areas such as toxicology, pre-hospital and retrieval medicine and international EM.

Perceptions of the ACEM trainee research requirement: the case for improving access and enhancing the experience.

Dear Editor, The study by Mitra and colleagues regarding the ACEM trainee research requirement (TRR) provides important insights into the perceived value of the two options available to trainees: the coursework pathway (CP) and the trainee research project (TRP). A significantly higher proportion of trainee respondents rated the CP as being useful for meeting the College’s learning objectives for research, with many commenting that it is an easier and quicker alternative to the TRP. These results help explain the overwhelming popularity of the CP. ACEM data (Table 1) indicate that over 90% of trainees now choose this option, with only 34 TRPs completed in the 12 months to July 2014 (ACEM Trainee Research Committee, pers. comm., 2014). Anecdotally, many elect to incorporate CP subjects into higher degrees, such as Masters of Public Health. The resounding message from Mitra and colleague’s study is that trainees consider the TRP to be a less efficient and effective means of achieving the TRR. Other commentators have previously asserted that the bar for the TRP is set too high, thereby discouraging trainees from participating in research and disadvantaging those who do. The primary purpose of the TRR should be to meet the College’s learning objectives for research. While the College has a responsibility to encourage scientific discovery, the TRP is a blunt instrument for doing so. A 2009 review, conducted prior to the introduction of the CP, established that the overall quality of TRPs was poor. For these reasons, alternate strategies (beyond the TRR) are required to foster trainee interest in research and grow the clinical academic workforce. At a minimum, the College must comply with the Australian Medical Council standards for specialty education. These require that all training programmes include ‘formal learning about research methodology, critical appraisal of literature, scientific data and evidence-based practice, and encourage the trainee to participate in research’. Australasian critical care colleges have adopted varying approaches to meeting this standard. For instance, all trainees in intensive care are required to undertake at least one formal research project. In anaesthetic training, the options are performing a clinical audit or critical appraisal, undertaking a postgraduate degree in research or contributing to a research project culminating in publication in a peer-reviewed journal. ACEM’s current approach is laudable because it gives trainees choice. While Mitra and colleagues have established that the CP is the preferred option of trainees, accessing recognised courses is not without challenges (mainly related to time and cost). For this reason, concerted efforts should be made to both improve access to the CP, and enhance the experience (and therefore attractiveness) of the TRP. Cost subsidisation is one mechanism of meeting the former objective, and might be achieved through partnerships with local universities. Given that EM trainees frequently provide voluntary teaching and supervision of medical students, universities could recognise this by subsidising

What lies beyond: Findings from the Early Careers Survey of new Fellows of the Australasian College for Emergency Medicine 2013-2014.

Department of Policy and Research, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia, Department of Emergency Medicine, Royal Brisbane andWomen’s Hospital, Brisbane, Queensland, Australia, MedSTAR Emergency Medical Retrieval Service, South Australian Ambulance Service, Adelaide, South Australia, Australia, and Department of Emergency Medicine, Austin Health, Melbourne, Victoria, Australia

Concomitant roxithromycin use among elderly patients taking warfarin resulting in significant over-anti-coagulation

There is a paucity of literature regarding the potential association between roxithromycin and excessive anti‐coagulation in patients taking warfarin. An interaction may have important health implications for these patients, particularly the elderly, who are at greater risk of bleeding events due to falls and consequent injuries, as well as major gastrointestinal haemorrhage.

Refractory hypotension treated with vasopressin after intentional clozapine overdose.

We report the case of a 21-year-old schizophrenic woman presenting to an Emergency Department (ED) 2 h after intentional ingestion of 2300 mg (23× 100 mg) of her own clozapine tablets. She did not have access to other medications. Her family found her in a drowsy state and she subsequently experienced a 5-min generalized tonic–clonic seizure. Paramedics found her to be unresponsive, tachycardic (130 beats/min) and hypotensive (80 mmHg systolic), with the latter responding to 1 liters of intravenous 0.9% saline. She further experienced a spontaneously resolving generalized tonic–clonic seizure en route to the ED.

Training in global health and international emergency medicine: Where to next?

The Trainee Focus section in this edition of Emergency Medicine Australasia explores training in global health (GH) and international emergency medicine (IEM). In the article by Thurtle et al., several emergency medicine (EM) registrars describe the benefits and challenges of working in resource-limited settings, and Phillips provides insights based on her experience as a mentor and remote supervisor. This introductory piece outlines recent developments in GH training, and reflects on the IEM learning opportunities currently available to Australasian EM trainees.

Insights into the development of a trauma short course for Australasian emergency medicine clinicians

Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia, Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia, Department of Emergency Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia, Department of Emergency Medicine, Austin Health, Melbourne, Victoria, Australia, and Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia

Fit for the future? The relevance of Emergency Medicine Australasia to current and prospective emergency medicine trainees.

Emergency Medicine Australasia (EMA) is to be congratulated on its 25th anniversary. For a quarter of a century, the Journal has fulfilled an important role in publishing original research and facilitating discussion in academic emergency medicine (EM). At this milestone, it is timely to review the value of EMA to current and future Australasian College for Emergency Medicine (ACEM) trainees. This article reflects on trends in EM training, medical publishing and Web 2.0, and makes suggestions for further modernisation of the Journal.

Life-threatening cardiovascular toxicity following ingestion of Chinese herbal medicine

Dear Editor, A 46-year-old Chinese woman of nonEnglish speaking background presented to the emergency department (ED) with peri-oral tinging and facial numbness within minutes, followed by nausea, vomiting, diarrhoea and abdominal pain 30 min after ingesting a decoction of Chinese herbal medicine (CHM). This was prescribed for acute-on-chronic lumbar back pain by a traditional Chinese herbal practitioner. Verbal instructions were given to boil the mixture of plant and animal material (Fig. 1) for 45 min prior to ingestion. The patient reported boiling the mixture for approximately 30 min, a shorter period of time than recommended. In the ED, she developed chest pain, pallor, diaphoresis, heart rate 140/ min, systolic BP 75 mmHg, generalised fasciculations and horizontal evoked nystagmus. Cardiac monitor showed alternating broad complex tachycardias; bigeminy, trigeminy and atrial fibrillation. Monomorphic ventricular tachycardia followed with haemodynamic instability (BP 70/ 40 mmHg) and decreased conscious state. After two biphasic synchronised electrical cardioversions (150 Joules), she reverted to atrial fibrillation (140/min) with a blood pressure of 90/50 mmHg following 1 L of intravenous fluid resuscitation. She received an intravenous loading dose of amiodarone (300 mg) followed by an infusion (37 mg/h) in addition to noradrenaline 10 mcg/min. Laboratory and radiological investigations including a CT angiogram of the chest, abdomen and pelvis were unremarkable. Following ICU admission, the Poisons Information Centre clinical toxicologist provisionally diagnosed aconite toxicity. Other toxin-related differential diagnoses included cardiac glycoside poisoning. Subsequent serum digoxin concentration was negative. The patient reverted to sinus rhythm after 2 h; vasopressor support was weaned over 60 min. Amiodarone was continued for 48 h with no further arrhythmia. Transthoracic echocardiography was normal. The patient was extubated after 36 h and made an uneventful recovery. The Chinese herbal practitioner reported prescription of ‘Chuan Wu’, ‘Cao Wu’ and ‘Fu Zi’ to improve general circulation and reduce musculoskeletal pain. There is no commercially available biological assay for aconite in Australia. Two independent Royal Melbourne Institute of Technology Traditional Chinese Medicine Practitioners confirmed the presence of aconite within the prescribed mixture. ‘Chuan Wu’, ‘Fu Zi’ (both derived from Aconitum carmichaeli) and ‘Cao Wu’ (Aconitum kusnezoffii) are the most common forms of aconite used medicinally. Aconite is traditionally prepared as a decoction to hydrolyse toxic plant alkaloids. Toxicity typically occurs after suboptimal preparation including insufficient boiling. Aconite alkaloids bind with high affinity to voltage-gated sodium channels causing persistent channel activation, hence the primary use of aconite as an analgesic. Predominant toxicological features relate to organ systems where sodium channel interference is detrimental; neurological, cardiovascular and gastrointestinal. Symptoms can occur within 10 min of ingestion. Aconite is

An incidental finding of Castleman's disease in a pregnant woman

A 32-year-old woman was found to have an incidental abdominal mass during her routine antenatal ultrasound scan at 20 weeks for her second pregnancy. The ultrasound study demonstrated a 3.8-cm well-defined hyperechoic lesion in the right side of the abdomen, lying between the right kidney and the inferior vena cava. The mass was separate to the right kidney, lying anterior and slightly medial to it. The patient had no significant past medical history other than gestational diabetes in her first pregnancy, which was carried successfully to term. She carried her second child to term and was referred subsequently to the General Surgical Unit at the Austin Hospital for investigation of the abdominal mass. Clinical examination of her abdomen was normal. An adrenal mass was initially suspected, and an abdominal computed tomography scan was performed. It showed a 4-cm welldefined round solid enhancing mass near the third part of the duodenum, with a small cystic component in its periphery (Fig. 1). Routine blood examinations were normal. At surgery, the mass was removed and determined to be a lymph node with a slightly thickened capsule. The surrounding anatomy was normal with no suggestion of disease external to the excised lymph node. Immunochemistry confirmed the presence of increased numbers of lymphoid follicles (CD21 and CD23 positive) with surrounding nodules of B-lymphocytes (Fig. 2). No Hodgkin cells were identified. A diagnosis of unicentric Castleman’s disease (CD), hyaline vascular type, was made. CD, otherwise known as angiofollicular lymph node hyperplasia, was first described in the literature in 1956. An uncommon lymphoproliferative disorder, it is a heterogeneous condition with two commonly accepted clinical patterns (unicentric and multicentric) and three pathological classifications (hyaline vascular variant, plasma cell variant and mixed variant). Unicentric CD (UCD) is most frequently of the hyaline vascular type, and in contrast with multicentric presentations, responds favourably to surgical resection, with radiotherapy being reserved for unresectable cases. Multicentric CD (MCD) is generally more aggressive, carries a poorer prognosis and is more amenable to chemotherapy than to resection. It is rarer than UCD. No consensus exists as to the most effective treatment regimen for MCD, though the combination of cyclophosphamide, vincristine, doxorubicin and prednisolone (‘CHOP’) is often used. Rituximab and tocilizumab have also been used successfully in some patients. UCD most commonly occurs in the mediastinum, though involvement of lymph nodes in the retroperitoneum, neck, pelvic cavity and