The Quay

Barnacle encrusted stumps remain.
Thrusting, vertebral fossils
From tidal glar pools and rising silt.

The bar is no longer dredged:
Time gently smudges over noisy, dark,
Dangerous memories:
Hard men stooping –
Their iron shovels grate on coal,
Organic metronomes in coal boat bellies.

I remember dimly the last coal boat
That hove to at the quay, then slipped away,
Leaving coal dust to settle, like age.

I’d leap and dive from great stone steps
Measuring days in the high tide times.
I fished here for pollock with dead-man’s-fingers
Torn cruelly from tortured crabs.

But now, luxury seafront apartments crowd
Like schoolyard bullies on the harbour walls
And the silt rises as the stories die.

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I’ve noticed a few people following me here rather than at my newer blog. I will eventually retire this blog and it has been taken over by so please follow me there instead. Other than reminders like this, I won’t be posting new content here. So follow me at instead

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Redirecting to

If you ended up here by following a link from Amal Mattu’s EKG of the week talk on pericarditis vs STEMI, please go to instead – I’m in the process of moving house!

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Moving house

In the spirit of FOAM (Free Open Access Meducation) I have been collaborating with Mike Cadogan from to migrate this blog to it’s own domain. There is some fine tuning yet to do, but the existing content is all now available on – if you follow the blog, and if you follow the RSS feed please change your settings to

Once I am up and running, there will be a few changes on the site, including guest authors among other things. Watch this space. Or more accurately, the other space!

This is the logo for the new site:


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I have scaled the pinnacle – retirement is all there is left

I am of course delighted with my receipt of the accolade of a F.UCEM Diploma from the Utopian College of Emergency for Medicine via although this is tinged with disappointment as their promise to invoke “legend” status was cruelly broken with a devious post-hoc goal-post-shifting manoeuvre akin to that performed by the authors of IST-3.

And if I want to overpunctuate something, damn it, I bloody will, @precordialthump !?!?!?!

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Not all ST elevation is STEMI – the follow up

So this ECG has generated a fair bit of interest and quite a few comments both here and on Twitter. I trickled out a bit more information in the second post, but here is the final act:

I figured there were essentially three options for this patient (with a few minor variations possible) given that it was midnight and the “cardiology” registrar was a covering respiratory registrar:

1) Activate cath lab
2) Treat like a non-STEMI and consider a cath in the morning
3) Get an Echo looking for regional wall motion abnormalities and use that to guide decision re. primary cath urgently or not

Frankly, I think these are all reasonable options, with only logistical differences. He is a young man, and with his story is going to score a cath at some point anyway – only the timing of it remains to be decided. I thought he had myopericarditis, but that his more severe pain from two days prior sounded suspicious for ischaemic pain, so I wasn’t prepared to ignore that. I toyed with the idea of a late night Echo-tech call-in, but elected to treat him as a non-STEMI-plus, in that he got aspirin, clopidogrel, heparin and in consultation with the very sleepy on-call interventional cardiologist (who I think liked my plan because he got to stay in bed, rather than beacuse of innate superiority to other approaches), a tirofiban infusion. An Echo was organised for the morning and he went to CCU.

Echo report (paraphrased summary):

  • Mildly impaired LV function with two regional wall motion defects (inferoposterior basal and mid segment hypokinesis) with an EF of 50%.
  • There was a tiny posterior effusion.
  • Valves and other chambers NAD other than mild TR.

He not suprisingly went for a cath that morning too:

  • LAD: 70% stenosis, diffuse disease
  • LCx: 100% stenosis
  • Proximal 1st obtuse marginal: 70% stenosis
  • RCA: 60-70% stenosis
  • Conclusion – triple vessel disease, culprit lesion in LCx, akinetic inferior wall

The serial troponins went from 16 to 9 to 6 over the next 24 hours. The patient was discharged and referred for a CABG. The discharge summary prepared by the cardiology resident didn’t mention myopericarditis, but in discussion with the cardiologist himself, it was clear that his opinion was that the patient indeed had myopericarditis secondary to his infarct, which almost certainly occured 2 days prior and correlated with his more severe and typical sounding episode of pain.

This ECG from just before his cath and Echo is much more consistent with myopericarditis, with widespread saddle-morphology ST elevation, PR depression, and PR elevation in aVR:

So there you have it – a late-presenting MI (perhaps STEMI?) AND myopericarditis. This syndrome of early post-MI pericarditis may be rarer in the post-thrombolysis/PCI era, and is also known as PIP or PAMISP. It’s a bit too early for the autoimmune mediated Dressler’s syndrome (which is definitely rare in the post-interventional era), as suggested by some commenters, which tends to kick in from around 2 weeks post-MI. From emedicine on the topic:

“The incidence of early pericarditis after MI is approximately 10%, and this complication usually develops within 24-96. Pericarditis is caused by inflammation of pericardial tissue overlying infarcted myocardium. The clinical presentation may include severe chest pain, usually pleuritic, and pericardial friction rub.

The key ECG change is diffuse ST-segment elevation in all or nearly all of leads. Echocardiography may reveal a small pericardial effusion. The mainstay of therapy usually includes aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Colchicine may be beneficial in patients with recurrent pericarditis.”

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Revisiting #ICEM2012 with @corbetron on Storify

I meant to link to this Storify piece by David Corbet on the remote delegate experience of NOT attending a major medical conference using the social media tools of Twitter and Storify to share and reverberate his experiences.

This is FOAM again – our reach is long, and our message is simple, useful and free.

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The FOAM project – more than the sum of it’s parts!

Mike Cadogan (@sandnsurf on Twitter, , is taking mighty leaps for mankind in creating a grand unifying resource for medical education (and particularly Emergency Medicine and Critical Care) by running with the FOAM concept germinated at ICEM 2012 over a pint or two of Guinness. He has coalesced the world of EM/CC blogging here:

For those who say, “FOAM, what’s that?” I will explain – we believe FOAM is the future of medical education and asynchronous learning, and stands for Free Open Access Meducation

Mike’s groovy little FOAM logo

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Previous Post

There is ST elevation in I, II and aVF (i.e. missing out III) and V5 and V6 (and a hint in V4). There is apparent ST depression in aVR, but as some of you point out, this actually represents PR elevation. Of note, III is NOT elevated, which makes an inferolateral STEMI pretty unlikely. One might also expect some ST segment depression in aVL, and clearly there is none. As mentioned in one comment, there is likely to be left atrial abnormality with an asymmetrically bifid P-wave most marked in II. The first TnT was 16….now what? Do you activate the cath lab? Is it clearly pericarditis, or could it be STEMI? Give me a plan…

the underneaths of EM

This 53 year old man is an ex-smoker, with HTN well controlled by a single agent.
He presented to the ED under duress from his wife and GP with intermittent atypical pain which is sometimes worse with exertion, has a slight pleuritic variation, and radiates to shoulders. He mentions a more severe pain 2 days ago lasting a couple of hours with onset at rest. This was preceded by about three weeks of occasional slight exertional dyspnoea and chest tightness.
This is his ECG with mild residual discomfort:

What are your thoughts?

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#ACEMWS2012 – The ACEM Winter Symposium from Cairns

The Twitter newbie @yarcusmong did a wonderful job of tweeting the recent Winter Symposium of the Australasian College for Emergency Medicine from Cairns. A snapshot of the analytics looks like this:


The full analytic and the transcript of the Twitter conversation can be accessed at the symplur website here, and customised as required.

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