Shared posts

01 Sep 21:53

Hyperrealistic Animal Illustrations and the Tools Used to Create Them

by EDW Lynch

Hyperrealistic Animal Illustrations by Karla Mialynne

Artist Karla Mialynne has created a series of hyperrealistic animal illustrations that she presents along with the various pencils, markers, and other tools used to create each image. She has more illustration work on her Instagram account. Some of her works are available for purchase at Original Urban Style.

Hyperrealistic Animal Illustrations by Karla Mialynne

Hyperrealistic Animal Illustrations by Karla Mialynne

Hyperrealistic Animal Illustrations by Karla Mialynne

Hyperrealistic Animal Illustrations by Karla Mialynne

photos by Karla Mialynne

via reddit, Bored Panda

25 Aug 13:17

Organ Donation: The Real Power Is In You

by Vanessa Ruiz

Marcel Fukuwara Brasil Anatomy Heart Ad

Marcel Fukuwara Brasil Anatomy Heart Ad 3D

Marcel Fukuwara Brasil Anatomy Lung Ad

Marcel Fukuwara Brasil Anatomy Lung Ad 3D

Brazilian digital artist Marcel Fukuwara helped shape these ads for the government of the state of Ceará in Brazil. The ad’s message, “The Real Power is in You,” encourages people to donate their organs to save lives. I think it’s a fun concept for a serious topic and very well executed to top it all off!

Marcel Fukuwara – Moderler
Sandro Grasset – Render
Marcus Vinicius – Art Director
Ad Agency – Propeg
Studio – Z-axis

View more of Marcel’s incredible 3D projects on Behance!



23 Aug 17:02

Finger Hands, Creepy Tiny Human Hand Finger Puppets by Archie McPhee

by EDW Lynch

Finger Hands by Archie McPhee

Finger Hands are deeply unsettling finger puppets shaped like tiny human hands. They come in a set of five, allowing the wearer to perform a creepy “high twenty-five.” Finger Hands are available for purchase at Archie McPhee.

Finger Hands by Archie McPhee

Finger Hands by Archie McPhee

images via Archie McPhee

submitted via Laughing Squid Tips

21 Aug 17:52

Why haven't you had kids yet?

by Matthew Inman
20 Aug 13:42

Krisztianna’s Eerily Exquisite Muertitas

by Vanessa Ruiz
Krisztianna Autumn Muertita

April Blossom Muertita

Krisztianna April Blossom Muertita

Krisztianna April Blossom Muertita

Krisztianna Winter Muertita

Winter Muertita

Krisztianna Winter Muertita

Krisztianna Autumn Muertita

Autumn Muertita

Krisztianna Spring Muertita

Spring Muertita

Krisztianna Summer Muertita

Summer Muertita

Krisztianna Muertitas collection

Krisztianna Muertita at work

California based sculptor, Krisztianna, creates these eerily exquisite Day of the Dead inspired mounted female heads after coming home from her day job as an Art Director at an advertising agency. She calls the heads Muertitasrecalling the importance of the Day of the Dead culture to her and her family when she was growing up.  Kristztianna says, “Birth, death, and rebirth are all fascinating concepts, and the the art of the sugar skull is a powerful visual that helps me express my joy of life and respect of finality.”

Driven by a fascination with storytelling, each Muertita represents a season captured by the crowning floral arrangements surrounding each face. The sculptures are made from a mix of styrofoam, paper maché, wire, clay, wood, acrylic, synthetic flowers, twine, pins, glue, sealant, screws, and as Kristzianna says, “lots of love.”

View more of Kristzianna’s work and information about the Muertitas at Photographic prints of the pieces featured above are available on Society6!


[Photography by Chris Rigg. Spotted by medical illustrator, David Cheney]




Day of the Dead Sugar Skull wallpaper available at the Street Anatomy Store

If you’re interested in the Day of the Dead head over to the Street Anatomy Store to see the wallpaper by Anatomy Boutique featuring the iconic sugar skull in gold on emerald and charcoal. 



19 Aug 17:33

quinoa puttanesca

by bridget

quinoa puttanesca 1

Based on whether it leaves a bunch of half-used ingredients leftover, this may not be the best single-person dinner, but it’s one of my favorite meals for when Dave is out of town anyway. For years, Dave didn’t like anchovies or olives, so those were the things I ate when he traveled. He’s come around to both, but the tradition has stuck, and this has become a treat for myself while he’s gone.

quinoa puttanesca 3

It’s very similar to the pasta version, but I like to think quinoa is a little healthier than pasta. Certainly, quinoa has a stronger, earthier flavor, which required adjustments in the other ingredients. More briny olives, more salty capers, and more bitter parsley were all necessary to stand out next to the quinoa.

quinoa puttanesca 4

Even if it doesn’t fulfill my no-leftover-bits-of-ingredients rule for single-person dinners, it meets the rest of my criteria – easy, healthy, minimal dishes. Fortunately, I like it so much that I’m willing to make it twice in one week while Dave travels, which is the perfect way to use up the half cans of tomatoes and tuna leftover from one serving. That puts this back on the list of great meals for cooking for one.

quinoa puttanesca 2

Printer Friendly Recipe
Quinoa Puttanesca (adapted from Cook’s Illustrated’s Spaghetti Puttanesca)

4 servings

I use the higher amount of anchovies, because I love them, but I understand that not everyone shares that opinion. The tuna is not at all traditional in puttanesca, but it increases the protein of this one-pot dish.

1 tablespoon olive oil
1 teaspoon red pepper flakes
6 cloves garlic, peeled and minced
6-8 anchovies, minced
8 ounces (1⅓ cups) quinoa, rinsed and drained
1 (28-ounce) can whole tomatoes, coarsely diced in the can with scissors
2 (5-ounce) cans solid white tuna in water, drained and flaked into bite-sized pieces (optional)
¼ cup capers, drained
1 cup kalamata olives, finely chopped
¼ cup minced parsley

In the medium saucepan over medium heat, heat the olive oil, red pepper flakes, garlic, and anchovies until sizzling and fragrant, 2-3 minutes. Add the quinoa, tomatoes with their juice, and tuna (if using). Increase the heat to medium-high and bring to a simmer. Once the mixture simmers, cover, reduce the heat to low, and simmer for 15 minutes. Stir once, then replace the cover, remove the pot from the heat, and let set for another 15 minutes. Stir in the capers, olives, and parsley; serve immediately.

14 Aug 10:00

R.E.B.E.L. ECG of the Week: Wellens’ Syndrome or STEMI

by Salim Rezaie

Wellens' Syndrome or STEMI

A 52 year old female with a past medical history of type II diabetes mellitus and tobacco abuse presents with a chief complaint of chest pain.

According to the patient she had about 2 – 3 months of stuttering, substernal chest pain without any radiation.  She described the pain as pressure-like, with activity, but that it would typically resolve after a few minutes of rest.  Today she awoke with substernal chest pain that never resolved and continued in the emergency department.  She quantifies her pain as 7/10 and not relieved with 2L nasal cannula of oxygen, 325mg PO aspirin, and SL NTG x3.

BP 127/89     HR 76     RR 20      O2 sat 100% on 2L NC     Temp 99.3

Awake, A&Ox3, appears uncomfortable
Mild JVD on examination
RRR w/o m/r/g
2+ pulses in her extremities, no edema

ECG is shown (No prior ECG for comparison)…..

Before reading on, try to come up with your own interpretation of this ECG before moving on to the final impression

Wellens' Syndrome or STEMI

Rate: 68
Rhythm: Normal Sinus Rhythm
Axis: Normal Axis
QRS: Left Ventricular Hypertrophy
ST/T Waves: Biphasic T- Waves in Leads V1 – V4, but there is also ST Elevation in Leads V1 – V3
Final ECG Interpretation: Anterior STEMI

Wellens' Syndrome or STEMI

Although this is a case of Anterior STEMI, lets discuss Wellens’ Syndrome….

History of Wellens’ Syndrome

Wellens’ Syndrome was first described in 1982 [1] in which 75% of patients with t-wave inversions in V2 – V4 went on to have an acute myocardial infarction.  This was again discussed in 1989 [2], and showed that all patients with this morphology had a > 50% LAD stenosis.  In the United States, 10 – 15% of unstable angina patients admitted will have this ECG finding.

What is Wellens’ Syndrome?

  1. History of Angina
  2. ECG Changes (T-wave Inversions/Biphasic T-waves in leads V2 – V4)
  3. Normal to Minimally elevated Cardiac Enzymes
  4. No pathologic precordial q waves
  5. No loss of precordial R wave progression

What are the Types of Wellens’ Syndrome?

Types of Wellens' Waves


Why does Wellen’s Syndrome Matter? [3]

  • Signifies a critical high grade proximal LAD stenosis
  • Myocardial infarction occurs within a mean of 6 – 8.5 days after admission
  • Myocardial infarction occurs within a mean of 21.4 days after symptoms

What is the Specificity of inverted T waves (V1 – V4) on EKG for proximal LAD stenosis?

Number of Patients
Haines DE et al (1983) 118 New T Wave Inversion Correlation to Significant LAD Stenosis 69% 89%
Kojuri J et al (2007) 130 T Wave Inversion Correlation to Significant LAD Stenosis in Patients Without MI 49.3% 96.6%

Remember: T-wave changes may be transient or resolve with medical management

What else can cause t-wave inversions in the anterior ECG leads?

  • Subarachnoid Hemorrhage
  • Pericarditis
  • Pulmonary Embolism
  • Takotsubo Cardiomyopathy
  • Electrolyte Abnormalities
  • HOCM
  • Pancreatitis

R.E.B.E.L. ECG of the Week: Wellens' Syndrome or STEMI - T Wave Inversion in Anterior Leads

Why should we not perform exercise stress testing in patients with suspected Wellens’ Syndrome? [4]

The only evidence for this is case reports, not large randomized control trials, but stress testing can prove fatal as there is minimal collateral circulation to the proximal anterior myocardium (i.e. “The Widow Maker”).

How do you treat Wellens’ Syndrome? [2] 

Oxygen, aspirin, nitroglycerin, and heparin or enoxaparin are the mainstay medical treatments of unstable angina, which is what Wellens’ Syndrome is, but in this specific case cardiac revascularization is also important. Specifically, how important is early revascularization vs medical management or delayed revascularization on morbidity and mortality?

R.E.B.E.L. ECG of the Week: Wellens' Syndrome or STEMI - Treatment of Wellens' Syndrome

  •  180 patients with Wellens’ ECG admitted and managed with either: Early Revascularization vs Medical Therapy
  • Less likely to die with early revascularization vs medical therapy and/or late revascularization (2.6% vs 17.9%)
  • Less likely to have AMI with early revascularization vs medical therapy and/or late revascularization (8.0% vs 30%)

Now Back to Our Patient… R.E.B.E.L. ECG of the Week: Wellens’ Syndrome or STEMI?

The reason our patient’s case is a STEMI and not Wellens’ Syndrome is….

Since the patient was having active symptoms and no old ECG for comparison, we activated the cath lab and the patient was found to have a 60% Left Main (LM) Artery lesion and a 100% ostial Left Anterior Descending (LAD) Artery lesion. First troponin before heart cath was 30. This turned into an evolving STEMI….or more eloquently stated a subacute anterior STEMI.

In summary our patient has:

  1. Having ACTIVE Chest Pain
  2. ST-Segment Elevation (STE) in V1 – V3
  3. Sensitive Troponin I of 30 is not minimal
  4. Absence of R waves in precordial leads

Clinical Bottom Line for Wellens’ Syndrome:

  • Wellens’ Syndrome signifies a high grade proximal LAD lesion until proven otherwise, but be sure to rule out other causes of ECG changes
  • The ECG changes of Wellens’ can be transient, so you must have a high index of suspicion
  • Stress testing, based on case reports, can induce a massive anterior myocardial infarction
  • The treatment of choice to improve both morbidity and mortality in Wellens’ Syndrome is early heart catheterization

For more on Wellens’ Syndrome Checkout:




  1. C. de Zwaan, F.W. Bär, and H.J. Wellens, "Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction.", American heart journal, 1982.
  2. C. de Zwaan, F.W. Bär, J.H. Janssen, E.C. Cheriex, W.R. Dassen, P. Brugada, O.C. Penn, and H.J. Wellens, "Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery.", American heart journal, 1989.
  3. E.B. Hanna, and D.L. Glancy, "ST-segment depression and T-wave inversion: classification, differential diagnosis, and caveats.", Cleveland Clinic journal of medicine, 2011.
  4. N. Sowers, "Harbinger of infarction: Wellens syndrome electrocardiographic abnormalities in the emergency department.", Canadian family physician Médecin de famille canadien, 2013.

The post R.E.B.E.L. ECG of the Week: Wellens’ Syndrome or STEMI appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

13 Aug 06:01

Frozen Herb Starters

by Sara@Our Best Bites

Fresh Herbs introFresh herbs are one of my favorite things about having a home garden, but they’re also one of the hardest things for me to keep up with.  They need quite a bit of trimming and pinching back to really stay viable and they can get out of control really quickly.  I use a lot of fresh herbs in my cooking, and I still can’t keep up with my own plants.  I started making these little frozen herb cubes years ago, (long before the idea went viral on Pinterest!) and thought it was about time I shared it here because it’s a great way to preserve the fresh flavors of summer and then enjoy them all year long in lots of different recipes.  It’s so quick and easy, you can feel really productive with your preserving skills.  And I’m all about easy things that make me feel productive!

Fresh Herbs

Continue reading: Frozen Herb Starters

The post Frozen Herb Starters appeared first on Our Best Bites.

11 Aug 20:36

Magician Levitates a Sausage Weiner in Front of a Few Dogs Just to See How They’ll React

by Lori Dorn

Jose Ahonen, the Finnish magician about whom we’ve previously written, performs a magic trick in which he levitates a sausage weiner in front a variety of absolutely adorable dogs, just to see how they’ll react. While some of the dogs weren’t exactly sure as to what what happening, it was all in fun and, as Jose says, “everyone got to eat the weiner in the end!”

12 Aug 18:14

‘Flower Power’, A Photo Series That Shows the Softer Side of Pit Bulls In Soft Light and Floral Halos

by Lori Dorn


Photographer Sophie Garamand, whose work we’ve previously posted, has a new series in which she portrays adoptable pit bull dogs in soft light and floral halos, giving them an angelic hippie look that is in stark contrast to the usual gritty urban environments in which these dogs are usually portrayed. Dogs from three different New York City shelters, Sean Casey Animal Rescue, Second Chance Rescue and Animal Haven, participated in the shoot.

This project started as an excuse for me to discover more about pit bulls. Like many people, I admittedly had prejudices against them. But as an active volunteer with many rescue groups, I often came in contact with pit bulls and was slowly warming up to their sweet nature. I decided to confront my apprehensions and explore their soft side in a visual way. I realized pit bulls were always portrayed in very urban, gritty photographs. The imagery associated with these dogs is often harsh, very contrasted, conveying the idea of them being tough. In my opinion, this feeds the myth that these dogs are dormant psychopaths.So I decided to take the other route and portray them like hippies, soft fairy-tale-inspired characters, feminine and dreamy. The idea of Flower Power blossomed.






photos by Sophie Garamand

via My Modern Met

12 Aug 18:37

Adorable Photos of a Couple Posing with Their Dog As If She Were a Newborn Baby

by EDW Lynch

Doggy Newborn Photos by Jamie Clauss

Photographer Jamie Clauss — a specialist in maternity and newborn portraiture — recently created this ridiculously adorable portrait series of a young couple and their “newborn” dog Snuggles.

Doggy Newborn Photos by Jamie Clauss

Doggy Newborn Photos by Jamie Clauss

Doggy Newborn Photos by Jamie Clauss

Doggy Newborn Photos by Jamie Clauss

photos by Jamie Clauss

12 Aug 19:40

‘My Drunk Kitchen’, A Book Featuring Hannah Hart’s Inebriated Cooking Misadventures

by Lori Dorn

My Drunk Kitchen

Hannah Hart, the star of the very popular web series “My Drunk Kitchen“, has released her new book My Drunk Kitchen:A Guide to Eating, Drinking, and Going with Your Gut, a collection featuring many of the recipes that she created during her inebriated cooking misadventures.

My Drunk Kitchen includes recipes, stories, full color photos, and drawings to inspire your own culinary adventures in tipsy cooking. It is also a showcase for Hannah Hart’s great comedic voice. Hannah offers key drink recommendations, cooking tips (like, remember to turn the oven off when you go to bed) and shares never-before-seen recipes such as:

  • The Hartwich (Knowledge is ingenuity! Learn from the past!)
  • Can Bake (Inventing things is hard! You don’t have to start from scratch!)
  • Latke Shotkas (Plan ahead to avoid a night of dread!)
  • Tiny Sandwiches (Size doesn’t matter! Aim to satisfy.)
  • Saltine Nachos (It’s not about resources! It’s about being resourceful.

The book is currently available on Amazon and through other booksellers.

Hannah and My Drunk Kitchen

images via Hannah Hart

08 Aug 01:43

New Whovian Etsy Items

by Kitty B

As you know, Kevin and I operate a thriving Etsy shop. You may also recall that we love Doctor Who. We were approached by to review their products, and jumped at the chance! It took us a week to think and determine what Kevin would be designing for the shop (and for our own personal use) and we came up with this:

We love every single one of these. My personal favorite is the fridge magnets. The price on these were great, and I could see so many cool opportunities for fridge magnets. I envision brides using them as save the dates, or it'd be a great way to show off your business instead of business cards! 

Kevin LOVES how the decal looks on his blue jeep too! So fitting seeing as how its a big blue box (and bigger on the inside).

Our items arrived just when they were supposed to, arrived safely and looked great
Great product, great website, great prices! 

*this is a product review request. I received product compensation in exchange for a review. All opinions are my own.

07 Aug 07:21

The Single Pancake

by joythebaker

The Single Pancake with blueberries and lots of chocolate

One of life’s small pleasures:  sharing breakfast with someone.

I mean… if you can find someone who will order the savory breakfast, but then let you pick at their hash browns… I’m pretty sure that’s a love for life.  The ultimate breakfast situation involves sharing an eggy-hash and then sharing a totally over-the-top pancake.  If you can find the human that wants to embark on this sort of breakfast endeavor with you, marry them or give them one of those BFF friendship necklaces.  Either way.  Shared breakfast is a big deal.

Breakfast isn’t always about a pair.  Heeeeck no!  The solo pancake expedition is just as important as the coupled pursuit.  This pancake recipe makes one giant pancake filled with fresh blueberries and chocolate pieces.  Just one!  Just one mega pancake with way too many fresh blueberries and a little too much chocolate.  It’s perfect for one hungry belly, or two bellies to serve after eggs as something I like to call… breakfast dessert.

The Single Pancake with blueberries and chocolate

This recipe comes together in little bits.

Little bits of flour and oats.  A little bit of sugar, cinnamon, and soda, powder.  A little bit of butter.  A lotta bit of fresh blueberries and chocolate.  Too many blueberries and too much chocolate… that’s really what we’re going for.

The Single Pancake with blueberries and chocolate

Dry ingredients frist.

Flour, oats, cinnamon, sugar, and the baking soda and baking powder.

It feels strange to mix together such small amounts.

The Single Pancake with blueberries and chocolate

Buttermilk because it’s nice, thick, and tangy, too!

If you don’t have buttermilk you can add dash of milk to yogurt and go with that!

The Single Pancake with blueberries and chocolate

Handfuls each of fresh blueberries and chocolate chips.  If it feels like too much, it is… and that’s exactly right.

The Single Pancake with blueberries and chocolate

The batter rests while the griddle heats.

You can make this batter as one single pancake (which is a monster and terrifying to flip) or as two small pancakes (which is civilized and easier to flip).  I went with one giant pancake because I like to be scared in the kitchen.  Next time (and there will be a next time), I’ll go with two small cakes.

The Single Pancake with blueberries and lots of chocolate

It’s Breakfast Dessert!  The most coveted meal / non-meal of the day!

The Single Pancake with blueberries and chocolate

As if sweet blueberries and melted chocolate weren’t enough for breakfast dessert… maple syrup and powdered sugar, too!?  Out of control.

The Single Pancake.  It is restrained in portion and totally bonkers in every other way.

The Single Pancake with too many blueberries and lots of chocolate

makes one large or two small pancakes

Print this Recipe!

1/3 cup all-purpose flour (a multi purpose gluten-free flour also works well)

1 Tablespoon dried oats (quick-cooking or old-fashioned)

2 teaspoons granulated sugar

1/2 teaspoon baking powder

1/4 teaspoon baking soda

pinch of salt

1 tablespoon unsalted melted butter

1/4 cup plus 2 tablespoons buttermilk

splash of pure vanilla extract

handful of fresh blueberries

smaller handful of dark chocolate chips

a bit of vegetable oil and butter for coating the griddle

In a small bowl, whisk together flour, oats, sugar, baking powder, baking soda and salt.  In a separate bowl whisk together melted butter, vanilla extract and buttermilk.  Combine the wet and dry ingredients and stir to combine.  The mixture will be thick.  Fold in the fresh blueberries and  chocolate chips.

In a small non-stick frying pan or a griddle  heat a teaspoon of oil and a dab of butter over medium heat.  Pour in the pancake batter and spread some with the back of a spoon.  Cook over medium heat until blueberries begin to bubble and the bottom of the pancake is golden brown.

Flip.  It’s ok if it doesn’t flip perfectly.

Cook until golden brown on both sides.  Remove from pan and onto a plate.  Top with maple syrup and powdered sugar.  Enjoy immediately.  


The post The Single Pancake appeared first on Joy the Baker.

05 Aug 19:00

How Fox Reacted To Guardians Of The Galaxy [Comic]

by Geek Girl Diva


firefly guardians

(via Reddit)

05 Aug 21:01

Lights Out In 71 Seconds

by Brinke

Mr. Man here has no intention of going to bed at the beginning of this clip, and is quite vocal about it. At the 1:11 mark, he’s toast.

As seen on the @CuteEmergency Twitter.

Filed under: Uncategorized Tagged: frenchies, Prolly an Encore Presentayshe but I can't find it
04 Aug 13:00

Basic Airway Assessment: It’s as easy as… 1-2-3?

by Rob Woods

In medical school, many multiple-choice questions in the setting of an acutely ill patient have an option of “managing the ABC’s” and it is always the correct answer.  Unfortunately, saying “I would manage the ABCs as my first priority” is very different from actually knowing how to assess an airway, let alone managing abnormalities during a trauma resuscitation.

If you think this is going to be some crazy airway blog post, think again.  This isn’t a sexy topic on cool, cutting-edge airway interventions…. It’s a bread and butter BoringEM topic that deserves attention. Read on for an approach to basic airway assessment.

Misconceptions about the “A” of ABC

The biggest misunderstanding is around the A of the ABC’s: Airway. In the trauma room I regularly hear the statement, ‘They are talking, so their airway is patent’.  This is inaccurate.  Patency is our primary concern in airway assessment, but the patient who can talk does not necessarily have a PATENT airway.  Think about a patient with bad airway edema from a laryngeal fracture, or a patient with an inhalational injury.  They can talk, but their airway may be closing nonetheless.  The ability to talk usually implies a PROTECTED airway, not a patent airway.  Lack of airway protection is a less urgent matter than patency.

PATENCY is assessed through the presence/absence of obstructive symptoms (stridor, secretions, snoring, etc.), or findings suggesting an airway that may become obstructed (singed nasal/facial hair, carbonaceous sputum, stab to neck with risk of expanding hematoma).

Managing the Airway

The next issue is that the indications for definitive airway management involve both airway and breathing, so just because the airway is patent and protected, it doesn’t mean the patient won’t need to be intubated.

In general, the indications for intubation are (Walls et al., 2012):

  1. Failure to oxygenate
  2. Failure to ventilate
  3. Failure to maintain airway patency
  4. Anticipated clinical course: going for imaging/OR (airway or breathing)

1 and 2 relate to breathing issues, 3 is about airway patency, and 4 is about airway protection.

Look before you Leap:  Assess the airway for difficulty of potential interventions

From here, there is confusion about assessing the airway for PATHOLOGY (patency and protection issues) versus INTERVENTIONS such as: Bag-Valve Mask ventilation (BONES or BOOTS), difficult Laryngoscopy & Endotracheal Intubation (LEMON), difficult Laryngeal Mask Airway (RODS) and difficult Surgical Airway (SHORT).

Deciding that something is wrong with the airway SHOULD be the easy part, and simple interventions will deal with the most immediate airway issue of obstruction. (These simple interventions being:  suction, jaw thrust, oral-pharyngeal airway, supplemental O2).

Deciding if a definitive intervention (i.e. intubation) is required and how to go about that takes a lot more experience and training. The table below contains mnemonics for assessing a patient for intubation, bag-malve-vask ventilation, LMA placement, and cricothyrotomy.

Airway mnemonics modified from the STARSTM Manual & Walls et al. (4th edition)

Difficulty Endotracheal Intubation Difficult Bag-Mask-Valve (BMV)
L   Look externally
E   Evaluate 3-3-2
M  Mallampati*
O  Obstruction/Obesity
N  Neck Mobility**
B Beard
O Obstructed/Obese/OSA
N Neck Stiffness / Neck Mass
E Expecting (Pregnant)
S Stridor / Snores (OSA)**
Difficult Laryngeal Mask Airway (LMA) Difficult Cricothyrotomy
R  Restricted Mouth Opening
O  Obstruction
D  Distorted airway anatomy
S  Stiff Lungs / Neck
S  Surgery
H  Hematoma, Have Infection (Abscess)
O  Obesity
R  Radiation
T  Trauma, Tumor

* this is of limited use in non-elective intubations (e.g. Trauma)
** technically, can add an extra “S” behind all these mnemonics, since Stiff Lungs always makes any positive pressure ventilation strategy more difficult.

A suggested approach to basic airway assessment

My approach to airway assessment for PATHOLOGY is to assess the “S’s” in 3 steps:

The S’s of Airway Pathology

Step 1: Is there evidence of airway OBSTRUCTION now – is it complete or partial?

Complete Obstruction:
Silence without chest rise or
See-Saw Chest movement (chest down, abdo up with attempted respiration – resulting from diaphragmatic excursion with a closed glottis/obstructed tongue)

*Complete airway obstruction needs immediate intervention – cardiac arrest is likely within seconds to minutes of complete airway obstruction.

Partial Obstruction
Stridor – airway swelling/compression by hematoma
Secretions – saliva, blood
Snoring – tongue relaxation
Smash – risk of teeth/blood in the airway

SIMPLE = jaw thrust, suction, OPA, supplemental Oxygen, BVM
ADVANCED = Definitive airway management

Step 2: Is there a risk of ANTICIPATED airway obstruction?

Singe or Sputum (carbonaceous) – risk of delayed airway swelling from inhalational burn
Stab or Swelling neck – risk of delayed airway compression from expanding hematoma or neck mass

Frequent re-assessment, early intervention (if skilled), early consultation with experts

Step 3: Is there a risk of Aspiration from failure to PROTECT their airway?

Sleepy (low GCS)

Definitive airway management if decreased LOC (impaired gag reflex) is going to be prolonged, is not easily reversible, is deteriorating, or if intubation will facilitate further investigations (ie CT Scan).

The level of consciousness can always change and along with it the ability to protect the airway from aspiration, however aspiration is not an immediate event the second your GCS hits 8 or less.  GCS < 8 is not an absolute indication for intubation.  Many intoxicated patients and post-ictal patients live with a GCS or 5 or 6 and wake up a few hours later.  They don’t usually aspirate, and can be managed without definitive airway protection. Alternatively the head-injured trauma patient with a GCS of 12 at presentation that is a 10 now probably needs definitive airway management.


Always assess the S’s of the Airway.  If they are all normal, you can be confident that you are NOT dealing with an immediate or impending airway issue of patency or protection.  If there are abnormalities in the S’s, simple airway interventions will temporize the situation until more experienced providers can assist with definitive airway interventions. The table below summarizes the three steps and nine S’s. This approach is illustrated in 3 cases below.

  Step 1: Is there evidence of airway obstruction now? Step 2: Is there a risk of anticipated airway obstruction? Step 3:Is there a risk of Aspiration from failure to PROTECT their airway?
Signs Symptoms Complete Obstruction
Silence without chest rise
See-Saw Chest movementPartial Obstruction
Stridor – airway swelling/compression by hematoma
Secretions – saliva, blood
Snoring – tongue relaxation
Smash – risk of teeth/blood in the airway
Singe or Sputum (carbonaceous) – risk of delayed airway swelling from inhalational burnStab or Swelling neck – risk of delayed airway compression from expanding hematoma or neck mass  Sleepy (low GCS)


Case 1

44 y o male, assaulted to head/face with baseball bat.  Brought to ED in sitting position in c-spine precautions, normal Vital Sign, GCS 15.

Airway Assessment for Pathology:
Deformed nose bleeding into pharynx, difficulty opening mouth/sore jaw, spitting up blood continuously.  No trauma to neck, no stridor, no singed hairs or carbonaceous sputum, no see-saw respirations.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: Partial airway obstruction from blood.  Awake and protecting airway.  Manage this airway with suction +/- supplemental O2, upright positioning.

Airway Assessment for Intervention:
History of Sleep Apnea, Obese, Beard, Unable to open mouth (likely from mandible fracture), and no neck mobility (c-spine collar).

Q: How should you proceed?
A: This person is a predicted difficult BVM, Laryngoscopy, LMA and Surgical Airway!  If you do need to intervene for a drop in GCS or loss of patency you would need additional airway experts to definitively manage this airway safely. 

Case 2

36 y o female single vehicle rollover on highway, brought in c-spine precautions.  GCS initially 15/15 by EMS, no signs of external head injury/trauma, complaining of abdominal pain.  Initial Vitals: HR 115, BP 92/68, RR/O2 sats normal.  On arrival to hospital, GCS now 11, HR 130, BP 68/40 with a distended abdomen (not pregnant).

Airway Assessment for Pathology:
Snoring respirations. No secretions, stridor, see-saw resps, singe or stab/swelling to neck.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: This patient has a partial obstruction from her tongue due to decreased LOC and should be treated with jaw thrust/OPA/supplemental O2. Additionally, she may fail to protect her airway due to a low GCS secondary to hypovolemic shock.  Her ability to protect her airway is likely to correct with blood transfusion.

Airway Assessment for Intervention:
This patient has no predictors of difficult airway intervention except for a c-spine collar.

Q: How will you proceed?
A: Don’t just do something… Stand there!  Intubation comes with a significant risk of hypotension, both from the drugs given as well as the effect of positive pressure ventilation on pre-load.  You would NOT want to intubate this patient until their BP improved, or you might end up running a code.  If their BP improves, it is likely that their LOC will as well, so you probably won’t need to intubate at all.

Case 3

14 y o male flipped his quad, with quad landing on his head, brought in c-spine precautions.  EMS reports the helmet to be split in two.  GCS 12 (E4, V3, M3) with blood draining from both ears.  No visible trauma to chest/abdo or extremities.  HR 55, BP 177/94, RR/O2 sats normal.

Airway Assessment for Pathology:
Low and declining GCS. No see-saw resps, snoring, secretions, stridor, smash, stab, singe.

Q: What is going on with this patient’s airway?  What should you do immediately?
A:  This patient is at risk of failing to protect airway and has obvious signs of skull fracture for which they will need a CT scan.  Although the GCS is more than 8, it is deteriorating.  Also, the most predictive aspect of the GCS is the motor score.  As this patient is demonstrating flexor posturing and early Cushing’s response (hypertension/bradycardia), there is a high likelihood of intra-cranial injury.  This patient will likely need to be intubated.

Airway Assessment for Intervention:
There are no predictors of difficult airway intervention in this patient except for c-spine collar.

Q: How will you proceed?
A:  You need to get definitive control of this patient’s airway.  Hypoxemia and hypotension contribute to secondary brain injury, so management of this airway should pay close attention to these issues.  You would want to use apneic oxygenation as part of your RSI to mitigate the risk of hypoxemia, and choose a sedative agent that will maintain their blood pressure.

Case 4

56 yo female trapped in a housefire, no traumatic injuries.  Wheezy and SOB on scene once extricated from hospital, treated with Salbutamol nebulizer en route to hospital by EMS.  Wheeze/SOB settled upon ED arrival. Normal vital signs, GSC 15.

Airway Assessment for Pathology:
Black soot at the back of the throat, singed eyebrows.  No stridor, secretions, snoring, see-saw respirations, stab.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: There is an impending loss of airway patency from airway edema.  Consider early intubation before airway before the swelling makes passing an Endotracheal tube difficult or impossible.

Airway Assessment for Intervention:
No predictors of difficulty for airway intervention.

Q: How will you proceed?
A:  Early definite airway management under the auspices of impending airway loss.  It’s impossible to know if she will swell in her airway or not, but if she does it could be life threatening.  Early management is the usual approach if there is reasonable suspicion for inhalational burn, although at times it is an unnecessary intervention.

Author information

Rob Woods
Rob Woods
Program Director at University of Saskatchewan
Rob Woods is the Program Director of the University of Saskatchewan Emergency Medicine Residency Program

The post Basic Airway Assessment: It’s as easy as… 1-2-3? appeared first on BoringEM and was written by Rob Woods.

31 Jul 14:00

Read Tom Hiddleston’s Thank You Letter To Joss Whedon For The Avengers

by Alan Kistler


Loki - Norse god of mischief, lies and evil – is a sympathetic yet clear villain in the Marvel Cinematic Universe, arranging for people to die and war to erupt just to ruin his brother’s coronation, later robbing people of free will as he attempted planet-wide genocide. But we still love seeing him in action and a large part of the credit goes to Tom Hiddleston, a superb actor and all-around sweet guy. This Friday, Joss Whedon: The Biography will be released and it includes an e-mail exchange between Hiddleston and the director/screenwriter of The Avengers and Avengers: Age of Ultron. The actor was so overjoyed at Loki’s role in the script for Marvel’s The Avengers that he was compelled to write a thank you letter.

The letters can be read after the break.


I am so excited I can hardly speak.

The first time I read it I grabbed at it like Charlie Bucket snatching for a golden ticket somewhere behind the chocolate in the wrapper of a Wonka Bar. I didn’t know where to start. Like a classic actor I jumped in looking for LOKI on every page, jumping back and forth, reading words in no particular order, utterances imprinting themselves like flash-cuts of newspaper headlines in my mind: “real menace”; “field of obeisance”; “discontented, nothing is enough”; “his smile is nothing but a glimpse of his skull” “Puny god”

Thank you for writing me my Hans Gruber. But a Hans Gruber with super-magic powers. As played by James Mason … It’s high operatic villainy alongside detached throwaway tongue-in-cheek; plus the “real menace” and his closely guarded suitcase of pain. It’s grand and epic and majestic and poetic and lyrical and wicked and rich and badass and might possibly be the most gloriously fun part I’ve ever stared down the barrel of playing. It is just so juicy.

I love how throughout you continue to put Loki on some kind of pedestal of regal magnificence and then consistently tear him down. He gets battered, punched, blasted, side-swiped, roared at, sent tumbling on his back, and every time he gets back up smiling, wickedly, never for a second losing his eloquence, style, wit, self-aggrandisement or grandeur, and you never send him up or deny him his real intelligence…. That he loves to make an entrance; that he has a taste for the grand gesture, the big speech, the spectacle. I might be biased, but I do feel as though you have written me the coolest part.

But really I’m just sending you a transatlantic shout-out and fist-bump, things that traditionally British actors probably don’t do. It’s epic.

Sweet, right? And here is Mr. Whedon’s reply:

Tom, this is one of those emails you keep forever. Thanks so much. It’s more articulate (and possibly longer) than the script. I couldn’t be more pleased at your reaction, but I’ll also tell you I’m still working on it … Thank you again. I’m so glad you’re pleased. Absurd fun to ensue.

Best, (including uncharacteristic fist bump), joss.

“Absurd fun” is an apt description of The Avengers. It’s good to see evidence that the folks behind the scenes had as much fun as the audience did watching the movie.

(via Collider)

29 Jul 13:00

These Amazing Fantasy Creature Sculptures Will Blow You Away

by Amy Ratcliffe

fantasy creatures 1

Lee Cross has skills. The talented artist has a knack for being able to sculpt life-like fantastical creatures that are breathtaking. The handmade critters appear to be armature wire covered in fabric, stuffing, and fur, and they come in a wide variety of sizes. They’re also fully posable! It’s like having an adorable, exotic pet without any of the work.

While she doesn’t take commissions or have an Etsy shop, Lee does offer her creatures on eBay from time to time.

See more of Lee’s work after the break.

fantasy creatures 2

fantasy creatures 3

fantasy creatures 4

fantasy creatures 5

fantasy creatures 6

fantasy creatures 7

fantasy creatures 8

fantasy creatures 9

fantasy creatures 10

(Wood-Splitter-Lee via GxG)

29 Jul 13:10

Salmon Sandwich with Creamy Dill Sauce

by Meghan B.

Getting back into the healthy eating routine is not so easy…

Salmon Sandwich_3

I have been trying to get inspired with new healthy recipes and lately fish has been the only way for me to start climbing back up on that diet bandwagon. Salmon in particular has been a welcome healthy (re)addition to my diet. I never seem to know what to make myself for lunch, so I thought, why not make a fresh salmon sandwich? 

This salmon sandwich is the ultimate lunch, particularly because it test just as heavenly warm as it does cold. It’s perfect for me to take to the office or to have as a casual lunch. Deceivingly simple to make AND it makes you feel somewhat elegant/sophisticated when you are eating it!

Salmon Sandwich_2

Unless you are me and end up with oh-so adorable dribbles of dill sauce running down your face (I hope you heard the sarcasm dripping from “oh-so adorable” there…). I might not be the most elegant of eaters, but I can’t possibly begin to care when a sandwich tastes as gosh darn good as this one does!

I rub the top of my salmon with a simple mixture of garlic powder, salt, and pepper which pairs perfectly with the slightly tangy creamy dill sauce and the peppery mixture of micro greens.

Salmon Sandwich_1

If only I could pair it with a glass of chilled white wine when I am at work… ;)

Recipe Tip: Any leftover creamy dill sauce can be kept in an airtight container for up to a week. 

Salmon Sandwich with Creamy Dill Sauce
My favorite fresh lunch packed with light and summery flavors. Perfect for taking with you to work or enjoying on a leisurely weekend.
Serves: 2
  • 2 salmon filets
  • ¼ tsp garlic powder
  • ¼ tsp kosher salt
  • ¼ tsp freshly cracked black pepper
  • Ciabatta
  • Micro greens
  • 1 cup light mayonnaise
  • ¼ cup reduced fat sour cream
  • ¾ tsp white wine vinegar
  • ¾ cup fresh dill
  • ¼ tsp kosher salt
  • 3 tsp capers, drained
  1. Turn your oven’s broiler to high. Line a small baking sheet with aluminum foil. Place the salmon filets side by side on the lined baking sheet.
  2. In a small bowl, mix together the ¼ tsp salt, pepper, and garlic powder. Rub the spice mixture evenly over the top of the two salmon filets. Place the baking sheet in the upper third section of the oven and broil on high for approximately 6 to 7 minutes, or until salmon reaches desired doneness. Remove from oven and set aside.
  3. In the bowl of a food processor, add mayonnaise, sour cream, white wine vinegar, dill, salt, and capers. Process until the mixture is well combined.
  4. Add approximately 1 tablespoon of the creamy dill sauce to one side of each slice of ciabatta. Add each salmon filet to the sauced side of two slices of prepared bread. Top with micro greens and the other slices of bread (sauce-side down). Enjoy immediately!


The post Salmon Sandwich with Creamy Dill Sauce appeared first on Cake 'n' Knife.

24 Jul 15:00

Tiny Tips: Non-Cardiogenic Pulmonary Edema / ARDS

by Teresa Chan

When you see a pulmonary edema on chest x-ray (CXR), the knee jerk reaction is to attribute it to heart failure.  But what might you be missing?

Not all the glitters is gold. And not all that is wet on CXR is just plain ol’ CHF.

Non-Cardiogenic Pulmonary Edema (NCPE) is better known to the world when it it is at its most severe form – i.e. ARDS (Acute Respiratory Distress Syndrome) or ALI (Acute Lung Injury).[1] However, for the purposes of linking the concept to the mnemonic (and the CXR findings), I have chosen to file it as a Tiny Tip under NCPE.

First recognized in military casualties in the first and second World Wars, NCPE is a commonly discussed entity in critical care.  In fact, an international group of experts has met in Berlin recently to redefine the definition of ARDS/ALI (see the post by the LIFTL guys on this topic for a great primer). [2,3] NCPE can be caused by direct insults to the lung tissue or indirect mechanisms such as systemic inflammation.

Mnemonic  for Causes for Non-Cardiogenic Pulmonary Edema


I nhaled Toxins (Ammonia, Chlorine, Phosgene, Nitrous oxide)
S IRS / Sepsis / Septic Shock

N eurogenic (seizure, strangulation, trauma)
O verdose (Heroin, methadone, cocaine)
T hyrotoxicosis

T rauma
H eat (Smoke! Remember to also consider carbon monoxide!)
E lectrocution

H igh altitude pulmonary edema
E mbolism (Pulmonary Embolism, Acute Gas Embolism, Amniotic Fluid Embolism)
A SA toxicity
R eperfusion or Re-expansion pulmonary edema (or Rocky Mountain Spotted Fever – This one is in here for the PGY5s: May the Force be with you until your quiz next year)
T ransfusion

Remember, this is NOT a comprehensive list, but it is a list that can help you think through alternative causes of a “wet” CXR.  Causes that it does not contain include Uremia, Cardiopulmonary bypass, DIC (RMSF is in the above list mostly due to this), other coagulopathies, pancreatitis… and more.

The mnemonic for this Tiny Tip, as well as a bunch of others, can be accessed and memorized using spaced repetition through Boring Cards as outlined here.


1.  Perina DG.  Noncardiogenic pulmonary edema.  Emerg Med Clin N Am ;21 (2003) 385–393. PMID: 12793620.

2. Nickson C.  Acute Respiratory Distress Syndrome (ARDS) Definitions. Life in the Fast Lane. Revised April 16, 2014.  Accessed July 13, 2014.  Available at:

3. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33. doi: 10.1001/jama.2012.5669. PubMed PMID: 22797452.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Tiny Tips: Non-Cardiogenic Pulmonary Edema / ARDS appeared first on BoringEM and was written by Teresa Chan.

28 Jul 17:00

That’s No Moon [Comic]

by Sean Fallon
25 Jul 12:31

Star Wars Darth Vader Lightsaber Barbecue Fork With a Hilt Modeled After the Sith Lord’s Iconic Weapon Design

by Justin Page

Star Wars Darth Vader Lightsaber BBQ Fork

ThinkGeek released an officially licensed Star Wars Darth Vader Lightsaber Barbecue Fork that has a hilt modeled after the feared Sith Lord‘s iconic weapon design. It is available to purchase online. This force-filled utensil would go great with the Star Wars Lightsaber BBQ Tong from The Fowndry.

Darth Vader loves nothing more than a grilled weenie, and the brand he likes best is Coruscant National (hey, they answer to a higher power: the Emperor). When Vader grills, he insists on using his favorite BBQ fork. You know, the one that looks like his lightsaber hilt? The one that we’re calling the Star Wars Darth Vader Lightsaber BBQ Fork.

Star Wars Darth Vader Lightsaber BBQ Fork

Star Wars Darth Vader Lightsaber BBQ Fork

images via ThinkGeek

via foodiggity

25 Jul 21:21

Survey Results for America’s Favorite ‘Star Wars’ Film and Character

by Rollin Bishop

538 Best Star Wars

FiveThirtyEight has posted some interesting survey results from a survey they recently ran based on the Star Wars films. The survey was run through SurveyMonkey Audience and collected 1,186 responses from June 3rd to June 6th. As it turns out, people still really hate Jar Jar Binks. More on the survey results is available at FiveThirtyEight.

538 Star Wars Characters

538 Star Wars Han or Greedo

images via FiveThirtyEight DataLab

26 Jul 16:44

Finding Rover, An App That Uses Facial Recognition to Help Reunite Lost Dogs with Their Humans

by Lori Dorn

Finding Rover is a handy free app that helps to reunite lost dogs with their frantic humans through the use of canine facial recognition.

Here’s how it works. If you ever lose your dog, the app will do an instant facial recognition search of all lost dogs in your area. Within seconds you’ll see a list of dogs’ photos with the contact information of the kind person (or shelter) who has the dog. Contact the person or shelter, and a blissful scene of face licking and tummy rubbing will follow. On the flip side, Finding Rover revolutionizes the process of helping lost dogs…Simply snap a photo and the app instantly shows you photos of matching dogs with the owners’ contact info.

The app is available via iTunes, Google Play or via the Finding Rover site.


Finding Rover Instructions

Finding Rover

Registering Your Dog

images via Finding Rover

via SF Gate, The Daily Dot

23 Jul 14:19

Shiba Inu Brownies

by Clockwork Lemon

Shiba Inu Brownies-1-2

This weekend, whilst baking a birthday treat for my Brother's 30th, I realized a slab of brownies could be decorated just like a cake or a batch of sugar cookies. Perhaps this fact was already obvious to everyone else seeing as it IS a flat, frostable surface.. but I thought I'd share the revalation just in case it wasn't. Think about it! Who wouldn't welcome a platter of fudgy, chocolate frosted brownies adorned with adorable decorations at their next party? Why should sugar cookies get all the decoration glory?

Since these particular brownies were for my brother, I made a design partly inspired by the hilarious doge meme (because my brother is my go-to technology guru and enjoys all things internet),  partly by some cute cartoons of shibas, but it was mostly inspired by.....



Shiba Inu Brownies-24

 .. my brother and his wife's new Shiba, Laika. They adopted her shortly before my brother's bday and THE CUTENESS.. how can so much cuteness exist within one tiny animal?

 I'll be sharing how to make the brownies, but first: more Laika photos. Feel free to scroll past them to get to the brownie instructions (if your heart is made of stone..)

Shiba Inu-11Just look at her back legs: tiny adorable drumsticks!


Shiba Inu-2That face! Pure puppy joy.

Shiba Inu-13and that belly.. oh my god the puppy belly.

Ok. Puppy quota filled. Brownie time!


Shiba Inu Brownies-1

The process began by drawing out the icing design along with some doge inspired captions. The best part about making royal icing transfers is you don't need to have mad piping skills to make a cute design. If you're good at drawing, draw a design out, then trace over it with icing. If you're NOT good at drawing simply print out a design or have someone else draw one for you. It's the poor-bakers version of a kopykake projector.

Royal Icing Transfer-1-2I like to photocopy the drawing, tape the copies to a table, place a piece of wax paper over top, tape it down, then lightly grease the wax paper with shortening.

Then, I use a wilton #1 tip to outline the drawing in black royal icing, and a #2 to fill in first the white details followed by the tan and red details. Once the transfers have dried I use a food colouring marker to add eyes, although a #1 tip and black royal icing works well too.

Two tips for royal icing transfers:

1. Make extra. These babies are delicate and it's better to have a few left over than is it to break a bunch and come up short. I often pipe out 4 - 5 extras because I'm clumsy and tend to snap them in half.

2. Give them day or two (or more if they are bigger/thicker) to dry completely. If you can, set up on a surface where you can leave them untouched for an entire day. If I know I'll be needing my table, I usually pipe them onto cookie trays that can be easily moved.


Shiba Inu Brownies-5For the brownies, I made a double batch of the fudgiest  of brownie recipes and once it was cool, spread a thick, even layer of chocolate frosting made with unsalted Stirling butter.

To decorate, I carefully peeled the Shiba transfers from the wax paper and placed them gently onto the frosting. Next, I piped out the doge captions then stuck the pan in the fridge to firm up the frosting.


Shiba Inu Brownies-17Once we got to my brother's house I sliced up the brownies and served them chilled.

And by "sliced up the brownies" I mean "was hopelessly distracted by Laika", it was a miracle that they came out even remotely square shaped.

  Shiba Inu Brownies-21But it's not my fault.

Happy 30th Chris!

(I've included recipes/instructions for the brownies and the royal icing transfers, but not for the chocolate icing. I like to make my icing free-hand/to taste and this one was a combo of salted butter, cocoa powder, icing sugar, and a splash of cream. Just mix butter, cocoa powder, and icing sugar and adjust to taste to find the right balance of chocolaty and sweet. Then (if it needs it) add a splash of cream or milk to smooth it out.)

Fudgy Brownies


Brownies (barely) adapted from The Patent and the Pantry

1 cup unsalted Stirling butter

1 cup cocoa powder, sifted

2 cup sugar

1/4  tsp salt

1 cup all purpose flour

1/2 cup milk

2 egg

2 tsp vanilla

1. Preheat the oven to 350 degrees and line an 9x13 baking pan with parchment paper

2. Melt the butter in a medium pot, then stir in the cocoa powder until smooth. Stir in the sugar and salt, followed by the flour, milk, egg, and vanilla. The batter will be very thick.  Use a spatula to spread the batter in an even layer in the baking pan. 

3. Bake at 350 for 25 - 30 minutes until the center is just set and the edges are starting to pull away from the pan. Use the parchment paper to pull the slab of brownies out of the pan and cool on a wire rack. I like mine to be slightly underbaked and served chilled for maximum fudginess. If you want them to be more chewy and firm, bake an additonal 5 minutes or so.


Royal icing for icing transfers

4 cups  icing sugar (powdered sugar)

3 tbsp meringue powder (available at stores that sell decorating supplies)

½ tsp lemon juice

½ cup warm water

1. In mixer bowl, stir icing sugar and meringue power until combined. Add lemon juice and warm water. Using the whisk attachment, mix on low to dissolve the sugar. Turn the mixer on high and whip until thick and glossy. Continue to whip on high until icing holds stiff peaks when you lift the whisk up. This should take about 3-5 minutes.

2. Tint the icing using gel food colouring (available at most craft/cake supply stores) then transfer them into piping bags fitted with a #1 tip for the black outline and any small coloured details and #2 tips for the larger areas of colour.

3. Carefully outline each drawing with royal icing.. Keep the piping tip a few centimetres higher than the cookie to prevent squished or smudged borders. Allow to dry 15-20 minutes. Then fill in the drawings with the appropriate colours. Allow the transfers to dry completely (1 - 3 days depending on how big/thick they are) before moving.

25 Jul 04:05

One-Pot French Onion Pasta

by joythebaker

one pot french onion pasta

I’m already anticipating Sunday.

Talk about putting the cart before the horse.  We haven’t even hopped around the weekend enough to make it to Sunday.

Sundays, I would argue, are the worst.  Actually… they’re the BEST but only between the hours of 8am and noon when we’re sleeping in, churching, brunching, or napping after pancakes.  After noon on a Sunday I find myself in the unfortunate task of pretending to be relaxed while stressing about the week to come.  We’ve talked about this before.  It’s called The Sunday Stresses, and it’s more real that we deserve.

Luckily there’s PASTA.  All healing, all comforting, all filling PASTA.  Thank you, Lord.  For real.

I have pasta every Sunday night.  I spoon myself an embarrassingly large bowl, sit cross-legged on the couch, watch Comedians In Cars Getting Coffee and just tear through a bowl.  I’m trying to fill the pit of Sunday Stresses and pasta usually works, until it doesn’t… but even still.

One Pot French Onion Pasta

This One-Pot pasta comes together easily and makes the house smell like an onion dream.  There’s just something so right about the smell of cooking onions.

While the onions, thyme, and chicken broth flavors have more of a Fall feel to them… well, The Sunday Stresses know no season.   Let’s just get some quality couch time in.  Let’s make out with pasta, just a little.


One Pot French Onion Pasta

Fat spaghetti pasta, chicken broth and water, onions halved and sliced, butter and olive oil, thyme and cheese and arugula and seasoning.  Everything! Let’s go!

One Pot French Onion Pasta

The onions.  Oh the onions.  They actually cook longer than the pasta itself.  The onions need a bit of caressing with butter and olive oil and low heat.

One Pot French Onion Pasta

Progress.  It’s hard not to hover and stir, but the onions do need quality time with the heat.  They need to sit and simmer a bit.

One Pot French Onion Pasta

This is about when I get super impatient and start to think of worms.

One Pot French Onion Pasta

Golden brown, studded with fresh thyme, seasoned with salt and pepper rather aggressively.

One Pot French Onion Pasta

Deglazing the hot pan with water and chicken broth.  The steam!  The best part.

One Pot French Onion Pasta

Welcome to the party, pasta!  We need you.

One Pot French Onion Pasta

We do a little dance on the stovetop.  Simmer with the lid on for a bit.  Stir with the lid off for a bit.  Simmer with the lid on again.  Fluff with the lid off.

It’ll all come together in about 10 magical minutes.

Related:  I need more magical minutes in all of my days.  RIGHT!?

One Pot French Onion Pasta

Taste and most likely add:  salt and pepper, way too much parmesan cheese, and handfuls of fresh arugula.

One Pot French Onion Pasta

By now your neighbors are likely knocking on the door because you made the world smell AMAZING! Share the pasta, not the stresses.

This pasta is both slightly sweet and salty.  As the onions cook down, they take on a tender and sweet quality.  It’s lovely, but you may find yourself adding a bit more salt and parmesan cheese than you might expect.  I love the spice that fresh arugula adds to the pasta.  Red pepper flakes are also divine.  You want to add cooked sausage too!?  Heck yes!

Happy Weekend!

One-Pot French Onion Pasta

serves 4

Print this Recipe!

3 medium yellow onions, peeled and sliced

3 tablespoons olive oil

1 tablespoon unsalted butter

salt and fresh cracked black pepper

3 teaspoons fresh thyme

2 cups water

2 1/2 cups chicken broth

12 ounces uncooked spaghetti

salt and fresh cracked black pepper, to taste

parmesan cheese

fresh arugula

Place a large heavy bottom sauce pan over medium heat.  Add the olive oil and butter and stir until butter is melted.  Add the sliced onions all at once.  Stir to coat the onions in the fat.  Allow onions to cook, undisturbed, for about 4 minutes.  Add salt, pepper and thyme and stir.  Allow the onions to cook for about 4 minutes at a time.  Lower the heat if the onions are browning too quickly.    The onions will begin to brown, break down, and resemble an onion jam.

When onions are entirely browned and completely soft (about 15 minutes), add the water and chicken broth to the pan.  Using a wooden spoon, scrape any burned bits off the bottom of the pan.  Add the pasta all at once.

Return to medium heat and bring to a simmer.  Place the lid on the pan and allow to simmer for 5 minutes.  Remove the lid to toss and stir the pasta for about 3 minutes.  Return the lid and allow to cook for another 5 minutes.  Remove the lid and taste the pasta for doneness.  There will still be just under an inch of liquid in the pot.  Allow the pasta to cook more (if it was still crunchy), or allow some of the liquid to cook off.  It’s about your preference.  I like a bit of the broth remaining.  Plus, the pasta will absorb more of the liquid as it sits.

To serve, spoon into large bowls, top with parmesan cheese and fresh arugula.  



22 Jul 10:00

Diagnose on Sight: Bilateral Leg Rash

by Jeff Riddell, MD

Erythema Nodosum

Case: A pre-teen girl, living in central California, recently started on fluconazole, now presenting with a bilateral leg rash. What is your diagnosis? Click on the image for a larger view.


Take Our Poll



Erythema nodosum, secondary to coccidioidomycosis


Erythema nodosum is a cutaneous reaction consisting of inflammatory, tender erythematous subcutaneous nodular lesions. The classically painful rash is located on the lower extremities and usually regresses spontaneously. It is associated with a wide variety of disease processes [1,2] including:

  • Most common cause: Streptococcal infections
  • Other causes:
    • Behcet’s syndrome
    • Oral contraceptive use
    • Pregnancy
    • Sarcoidosis
    • Tuberculosis
    • Viral infections

Coccidioidomycosis is endemic to certain arid parts of the Southwest United States. Erythema nodosum is the most characteristic reactive cutaneous manifestation of coccidioidomycosis. It presents 1-3 weeks after onset of illness and is usually self-limited [3]. While strep infections are the most common cause of erythema nodosum, in a patient who has recently visited the American southwest, suspect coccidioidomycosis.


Master Clinician Bedside Pearls

Stuart Swadron, MD




Stuart Swadron, MD – Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California (provided to ALiEM and recorded by Swadron, 2014)



  1. Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol. 2000;19(3):212-6. PMID: 10870657.
  2. Schwartz R, Nervi S. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007 Mar 1;75(5):695-700 PMID: 17375516.
  3. DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol. 2006 Dec;55(6):929-4.2 PMID: 1711021.

Author information

Jeff Riddell, MD

Jeff Riddell, MD

Chief Resident

UCSF-Fresno Emergency Medicine Residency

| Twitter |

The post Diagnose on Sight: Bilateral Leg Rash appeared first on ALiEM.

30 Jun 22:22

Update on Age-Adjusted D-Dimer

by Salim Rezaie

burns was talking about this at a journal club a while ago...

Update on Age-Adjusted D-DimerD-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. The result of this would be that older patients would often have more diagnostic imaging or downstream testing, but on the other hand, maybe a higher cut-off d-dimer value may lead to increased false negative cases (i.e. missed venothromboembolism) and make this strategy less safe. Recently, I wrote a post on age-adjusted d-dimer testing on REBEL EM, but since that post there was a new article that was published in Chest 2014. This post, will specifically focus on an update of age-adjusted d-dimer testing based on the above article.

What article will we be discussing?

Woller SC et al. Assessment of the Safety and Efficiency of Using an Age-Adjusted D-Dimer Threshold to Exclude Suspected Pulmonary Embolism. Chest 2014. [Ahead of Print] PMID: 24831769

What is the clinical question we are trying to answer?

Is the use of age-adjusted d-dimer testing in patients ≥ 50 years of age safe for clinical practice?

What did they do:

  • A retrospective review of 923 patients, age > 50 years evaluated for suspected PE
  • All patients had a Revised Geneva Score (RGS) calculated, a d-dimer performed, and a computed tomography pulmonary angiography (CTPA)
  • A 64-slice CT scanner was used and high sensitivity d-dimer test (Stago latex agglutination)
  • Compared false negative rate for PE of a conventional d-dimer threshold with an age-adjusted d-dimer threshold



  • 104 patients had a negative CONVENTIONAL d-dimer and RGS ≤ 10, with NO PEs observed within 90 days (False Negative Rate = 0%)
  • 273 patients had a negative AGE-ADJUSTED d-dimer and RGS ≤ 10, with 4 PEs observed within 90 days (False Negative Rate = 1.5%)
  • AGE-ADJUSTED d-dimer resulted in 18.3% absolute reduction in patients age > 50 years who would undergo CTPA vs CONVENTIONAL d-dimer
  • In a subcohort evaluation a negative AGE-ADJUSTED d-dimer and RGS≤ 10 was seen in:
    • Age > 50 years: 273/923 pts with 4 (1.5%) missed PEs at 90d (95% CI 0.4 – 3.7)
    • Age 51 – 65 years: 130/480 pts with 1 (0.8%) missed PEs at 90d (95% CI 0.02 – 4.2)
    • Age 66 – 74 years: 66/186 pts with 0 (0.0%) missed PEs at 90d (95% CI 0.0 – 5.4)
    • Age ≥ 75 years: 77/257 pts with 3 (3.9%) missed PEs at 90d (95% CI 0.8 – 11.0)


  • If you look at each of the sub cohorts in the results section, the maximum confidence interval ranged from 3.7 – 11.0% increasing with age, which means we are potentially missing more PEs in older patients (i.e. upto 11.0% at the maximum CI in patients 75 years and older)
  • LimitationsThe prevalence of PE in this study was 10.6%.  In the US prevalence has been reported as 5.1% [1], but in contrast in European studies the prevalence for PE ranges from 24 – 31% [2] [3] [4].
  • This study was a retrospective chart review, so if hemoptysis or leg edema were not recorded they were considered negative, and actually underestimate RGS.  Also how may patients don’t go to doctors and have not had their initial malignancy diagnosed?  This will also reduce the RGS, when it is well known that malignancy risk increases with age
  • All patients in this study received a CTPA, which is not what is done in clinical practice, and excluded all patients who did not receive imaging.  Therefore this study population differs from an unselected patient population, making this a higher risk population for PE

Authors’ Conclusion: Using an age-adjusted d-dimer threshold reduces imaging among patients age > 50 years with a RGS ≤ 10, but at the cost of missing an additional 1.5% of PEs and requires a prospective study before this practice can be adopted into routine clinical care

Take Home Message

Take Home Message

Using an age-adjusted d-dimer strategy in patients age > 50 years would result in 18.3% fewer scans, but would miss up to 3.7 – 11.0% of PEs at 90 days of follow up based on the highest confidence intervals.  Therefore a prospective, randomized control trial with narrower confidence intervals would be needed before implementing this strategy into clinical practice



  1. A. Penaloza, P. Roy, J. Kline, F. Verschuren, G. LE Gal, S. Quentin-Georget, N. Delvau, and F. Thys, "Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism.", Journal of thrombosis and haemostasis : JTH, 2012.
  2. R.A. Douma, G. le Gal, M. Söhne, M. Righini, P.W. Kamphuisen, A. Perrier, M.J.H.A. Kruip, H. Bounameaux, H.R. Büller, and P. Roy, "Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts.", BMJ (Clinical research ed.), 2010.
  3. M. Jaffrelot, F. Le Ven, P. Le Roux, V. Tissot, E. Rame, P. Salaun, and G. Le Gal, "External validation of a D-dimer age-adjusted cut-off for the exclusion of pulmonary embolism.", Thrombosis and haemostasis, 2012.

The post Update on Age-Adjusted D-Dimer appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

21 Jul 14:21

Two Skydivers Jump From 5,000 Feet and Successfully Land on a Slip ‘N Slide

by Brian Heater

In this footage by Caters News, skydivers Niklas Daniel and Brianne Thompson leap from a plane at 5,000 feet above Arizona and manage to successfully land on a Slip ‘N Slide, traveling the length of the backyard toy at 50MPH.