RIP Dr. John J Hinds

#DeathIsAWanker-3St.Emlyn’s loves you John.

Thanks for being awesome and for sharing so much.

We will miss you terribly.



Please pass on your thoughts to the family via Rob Mac Sweeney (see below)

Links to some of the great work John was involved with

And of course

My top 5 reasons to attend #SMACC this year…



So I am back from an amazing few days in Chicago where the most amazing medical conference of the world just took place at McCormick place in Chicago (USA).

As a FOAM(ed) convert and avid Twitter user, I had been so far only a passive follower of this annual gathering of inspirational speakers but decided this year to attend the conference personally on the constant gentle nudging of a colleague and mentor of mine @EMManchester.

There is an argument that in the 21st century there is no need to physically attend medical conferences as most of them are relayed on social media via Twitter, YouTube, online material posts etc.  I will come back to that later.

I boarded the plane in Virchester for the windy city with a rather sceptical mindset but some degree of trepidation and landed at Chicago O’Hare airport having traveled back in time (time zone wise!) a few hours.

I was planning to have a couple of hours rest and visit the city before the academic event but my Twitter account kept buzzing of activity and I therefore found myself in a restaurant downtown with a burger washed down with some rather good american ale.

My trip had started a few hours ago only and I already managed to have a social catch up with the lovely @_NMay and some fellow emergency physicians and paramedics from Oz and the USA. Funnily enough, I had never physically met @docib who is integral part of our StEmlyns team at Virchester and an EMP in the UK so it was rather odd to finally meet him…across the pond.

The few days before the conference flew by rapidly filled in with some cultural programmes like a visit to the Art Gallery, a boat tour of the skylines of the city and food gatherings with amazing people from the four corners of the planet. It was amazing to finally physically meet face to face some of the leading figures of emergency and acute care.

The conference itself was attended by approximately 2,000 delegates and after an american style opening ceremony (jazz music, cheerleaders, confettis ), the real event unfolded with legendary  speakers like Scott Weingart, Cliff Reid, Rob Rogers, Liz Crowe  (to cite only a few!).

Themes for the talks ranged from cutting edge respiratory support to resilience for emergency physicians through our lost connection with the spiritual world.

As a conference which had truly embraced social media and  in the true spirit of FOAM(ed), real-time debates were taking place during and after sessions via the use of Twitter and questions to the speakers were also collected this way.

The tea and lunch breaks were another opportunity to catch up with the delegates and speakers who were very approachable and keen to meet with everyone. The attire of some delegates was somewhat…relaxed.




The gala dinner at Chicago Navy Pier was a success on all levels! The  theme for this year was “festival chic” (open to a wide range interpretation as you can imagine) and the British Virchester team turned up in James Bond tux and bow tie attire (which resulted in a few selfies and congrats from the crowd).

You cannot take care of the sick if you do not pay attention to your own mental and/or physical health so a group of delegates had even organised group runs along the shores of the river Chicago and Lake Michigan. Quite a performance (from me)!


It would be difficult for me to go through the benefits of attending #SMACCUS through a single blog so I tried to summarise my top ones below:

1. the conference was a true cutting edge professional meeting presenting the latest progress in the fields of emergency, pre-hospital medicine and acute care

2. as mentioned earlier, I finally connected physically with some truly inspirational people whose name I knew only through social media or as authors of published articles

3. I reconnected with some old friends and colleagues I had not seen since my university or specialty training years

4. this event was a definite drive for me to make some things change for the better in my own organisation

5. I had the opportunity to attend some of the innovative pre-conference workshops


Attending such a huge professional event can be daunting for the beginner and I would suggest the following tips if you are a “SMACC virgin”:

1. Book early to benefit from discounted conference and hotel fees. Keep in mind that it is an investment worth your money in terms of education, development, networking.

2. Reduce hotel costs by sharing a room with a colleague or friend. Some of the StEmlyns authors teamed up and roomie tales are always a laugh!

3. Become acquainted with twitter prior the conference. You do not have to be a pro but there is loads going on online before, during and after the conference too. Of course nothing stops you from attending the conference without social media: SMACC is not a conference for the geeks (only).

4. Remember that a conference is also a social event so join the official gala dinner, impromptu bar gatherings, city sight-seeings etc. Some delegates attended a baseball match and a U2 concert this year!

5. Do not be shy: go over and say hello. Chances are you already know each other on social media and everyone is much engaging.


Having returned to the UK a few days ago and back to my daily clinical work, my head is still spinning with the fantastic social and professional meets with inspirational colleagues. I can feel on me the signs and symptoms of a mythical illness called #SMACCDown: lassitude mixed with inspiration,  sadness mixed with joy,

I however feel revitalised again thinking the next SMACC event that will take place at our doorsteps in Dublin in June 2016.

So, have you got any valid reason not to attend in order to celebrate our noble profession?






#smaccUS day 1. A bountiful cornucopia of Medutainment.

Screenshot 2015-04-16 10.12.21

Day one at #smaccUS did not disappoint. An amazing musical start to the day followed by an intense plenary session with some of the luminaries of the #FOAMed movement.

The five concurrent sessions were a real challenge for the team. Where to go and what to see. A bountiful cornucopia of medutainment across a range of subjects.

Don’t forget to check out the workshop podcast here.

You can also check the thoughts of our friends from Birmingham on the HEFT cast here.

Catch up with what the St.Emlyn’s team learned on the podcast.

Before you go please don’t forget to…



#smaccUS day 0 – the workshops. St.Emlyn’s


The St.Emlyn’s team (well some of them) are currently at the greatest conference in the world. If you don’t know about Social Media and Critical Care Conference then seriously you must have been living under a rock.

This week we will be podasting, tweeting and blogging daily so keep an eye on our twitter feeds, follow the blog and subscribe to us on iTunes.

To kick us off let’s hear about the fabulous workshops on day 0……

Then check out day 1 here.




Before you go please don’t forget to…

Torticollis: A Real Pain in the Neck


By the time you’ve worked in the Emergency Department for more than a week it’s highly likely you’ll have seen a patient who has a bit of a sore neck after a relatively minor bump in their car. A little less often we see patients presenting with a fixed torticollis, their head held over to one side with pain associated with attempts to return it to a normal position. Torticollis as a presenting symptom can represent a number of pathologies, some of which are related to dystonia. The word torticollis comes from the Latin tortus (twisted) and collum (neck).

The torticollis can occur in a variety of directions:

Simple torticollis where there is no rotation of the head but uneven muscle tone present

Rotational torticollis where the face is turned towards the shoulder

Lateral torticollis where the head is tilted, ear to shoulder

While this is often benign, you’ll be pleased to know that it’s yet another seemingly innocuous condition which can sometimes represent some important and sinister pathology and as such it’s worth thinking about carefully, both in the context of immediate management and appropriate safety-netting, review and follow-up.

“A Car Drove Into The Back Of Mine!”

In those with a history of trauma, cervical dystonia can occur relatively quickly after trauma (immediately to a few days afterwards) or quite some time afterwards (delays of a few months have been reported although I wonder how reliably these can be attributed back to initiating trauma, particularly for minor injuries).

The trauma is usually associated with immediate pain and followed by a reduced range of movement and abnormal head posturing. If the patient has a history of trauma and meets criteria for imaging then radiographs may be helpful as dystonia can occur in the presence of bony injury. While movements should be minimised, please don’t try to force these patients into a rigid collar!

Just be careful and thorough with these patients. Perform a neurological examination and check the history carefully to make sure there are no features which might point you to possible sinister causes – think fever, weight loss, night sweats, reduced appetite…

In patients with a significant mechanism of injury, torticollis is an ominous sign. It is often associated with unifacet dislocation or fracture of the occipital condyle (which follows a high-energy injury). These patients frequently have associated neurological findings and often need cervical spine CT and subsequent MR scan – a chat with your friendly radiology colleague is required!

“Doctor, That Vomiting Girl in Bed 6 Looks a Bit Funny…”

Certain medications can precipitate acute dystonic reactions. For dystonic reactions developing acutely in the ED the most likely culprit is metoclopramide and acute oculogyric crises are most commonly seen with metoclopramide in young women, although patients may present in a similar way after taking their own phenytoin, carbamazepine or antipsychotics. Patients often have speech disturbance or staring. The recommended treatment in the UK is intravenous procyclidine 5-10mg for acute dystonia and it is usually effective in 5-10mins.

The video below shows a frightening reaction to metoclopramide; it’s easy to see why patients will need a good deal of explanation afterwards!

“I Just Woke Up Like This, Doc.”

Most often (around 85% of cases) there is no clear history of trauma; the patient has simply woken up like this in the morning. Acute idiopathic torticollis is the most common presentation – there is no history of trauma, the adult wakes with the neck stuck in a particular position and the vast majority of cases will resolve spontaneously within 1-2 weeks. There was an RCT of benztropine for the relief of acute non-traumatic neck pain (not FOAM) in the EMJ in 2014 which failed to demonstrate superiority.

“My Neck Hurts and I Don’t Feel Well!”

While acute idiopathic torticollis can present in children as well as in adults, it can also be a sign of some underlying nastiness and this is more true of the paediatric population (though it can occur in adults as well).

Torticollis can be associated with infection of the structures of the neck: think pharyngitis, tonsillitis, retropharyngeal abscess, otitis media, osteomyelitis, sinusitis, adenitis and even upper lobe pneumonia. Look for sickness in these patients who may not automatically have their vital signs recorded at triage. In the presence of fever or tachycardia, or in a patient who also reports constitutional symptoms, examine fully and investigate for possible infections.

We do occasionally see torticollis as a first presentation of a neoplastic cause; tumours in the cerebellopontine angle/posterior fossa cause a compensatory torticollis, so neurological examination of upper limbs, lower limbs, gait, co-ordination and cranial nerves is also important (you might alternatively identify the congenital strabismus or nystagmus which has led to the compensatory torticollis).

Finally, children can have atlantoaxial subluxation (C1 on C2) which may be related to juvenile arthritis or result from ligamentous laxity following infection in the neck (Grisel’s syndrome). This free electronic poster below outlines three typical paediatric clinical cases of non-resolving torticollis and shows the importance of follow-up – click the image to see a bigger version in PDF format.

Screen Shot 2015-05-03 at 17.36.47

These conditions may not be apparent at first presentation and since most are idiopathic and self resolving, follow-up is key; particularly in paediatric patients. If the symptoms are persisting, imaging of the brain and cervical spine is appropriate (MR scan is probably better than CT).


“My Baby is Making Weird Movements!”

Congenital torticollis is rare and usually related to in-utero positioning or birth trauma causing abnormal neck positioning, presenting in the first few weeks of life. Ultrasound can confirm the diagnosis and the muscles involved (most commonly ipsilateral sternocleidomastoid).

Sandifer syndrome may also cause paroxysmal dystonia with opisthotonic posturing: this is associated with reflux in babies (the diagnosis is more likely if episodes are associated with feeding) and can be very frightening for parents who think their baby is having a seizure.

So in summary:


  • Most are atraumatic and spontaneous and will resolve spontaneously: analgesia (and possibly benzodiazepines) constitute first-line treatment
  • If there is a history of a traumatic mechanism of injury, imaging can be helpful
  • Thorough assessment for potential infection and neurological signs is very important (the key here is thorough history-taking and examination)
  • Those which are not resolving should be reassessed; consider planned follow-up for kids and clear safety netting for all patients



Before you go please don’t forget to…

Meducation in Virchester #FOAMed