New Releases by Tim Egan

Dodsworth and his duck companion have a lovely time in Rome, even though the duck tries to improve the ceiling of the Sistine Chapel and takes all the coins from the Trevi Fountain.

CALM: A NON- PHARMACOLOGICAL AIDE-MEMOIRE TO REDUCE ANXIETY AND IMPROVE PATIENT EXPERIENCE IN AWAKE HAND SURGERYCo-authorstC.L. Pang1, I. Lewin1, T. O''Neill1, T. Egan1.1Royal London Hospital, Anaesthesia and Perioperative Medicine, London, United Kingdom.tBackground and Aims:Surgery in the awake patient is associated with elevated levels of perioperative anxiety. Our centre developed a non-pharmacological aide-memoire designed to reduce anxiety and improve patient experience across 4 different metrics: Comfort, Anxiety, Looking (the ability of the patient to see the operation), and Music.Methods:This quality improvement project was carried out at the Royal London Hospital. Prior to its introduction, patients were surveyed on the four components of the aide memoire to establish current practice. The aide was then introduced to all members of staff working on the plastics hand surgery list at the morning briefing. It formed a dedicated section of the WHO surgical time out for every patient. Following the introduction of the aid, a repeat survey was performed to determine its effectiveness in improving patient experience.ResultsThis aide memoire was effective in decreasing self-reported levels of anxiety and increase levels of comfort in our patients. The two main areas of anxiety in our pre-intervention survey related to patients being able to see or hear the procedure being performed. Subsequent to our intervention, the majority of patients were unable to see the surgery (as the drape was repositioned on their request), and had been given information which meant that they were able to listen to audio material of their choice during their procedure.Conclusions:This simple, non-pharmacological method of reducing anxiety is effective in our population of patients undergoing awake hand surgery. It is likely to have similar benefits for patients having other awake procedures in our hospital.

As a Major Trauma Centre we have a large volume of chest trauma. The mainstay of treatment for this group of patients is adequate analgesia and at our centre regional analgesia techniques are the preferred option for severe chest injuries, except where a contraindication exists. We were able to minimise delays and streamline our service through the introduction of an easy, inexpensive block bag to centralise the equipment needed for our regional techniques. This was a very easy and transferable way to remove common barriers to regional anaesthesia.

Background and Aims:Rib fractures are a major cause of trauma morbidity and mortality. Analgaesia is paramount, as uncontrolled pain leads to hypoventilation with its attendant complications. Regional anaesthesia (RA) is the standard of care; it is often underutilised. Provided no contraindication, NHS England stipulates that RA is provided within 6 hours of radiological diagnosis. This audit evaluates current practice at a London major trauma centre.Methods:Data were obtained from the Trauma and Audit Research Network database over 3 months commencing October 2018 for patients with u003e=3 rib fractures or chest drain. We recorded time from diagnosis to consideration and performance of RA, and qualitative data on choice of analgesia, service delays and complications.Results37 patients were admitted; 28/37 male, aged 68.8yrs (55.6-79.8), ISS 24 (17-34). We excluded 4 patients without valid identifiers; a further 3 had unsurvivable injuries. In 11/30 RA was considered within 6h, rising to 18/30 in total (range 0-u003e140h), with 7/30 eventually receiving RA. In 10/23 epidural/PVB was contraindicated.Some received sequential procedures: initial failure, or single-shot temporization followed by catheter. Reasons for non-provision are documented in Figure 1. In 7/7 patients, RA was delayed u003e24h from diagnosis.Conclusions:- RA considered early in majority of cases;

U201cGold Standard Perioperative Analgesia for Severe Chest Trauma u2013 meeting the NHS England Major Trauma Services Quality Indicatorsu201dDavid Burtle1, Gurjinderpal Singh Pahal2, Tim Egan31 ST4 Anaesthetic Registrar, BLSA2 Consultant Plastic Surgeon, RLH3 Consultant Anaesthetist, RLHIntroductionRib fractures are common with severe blunt thoracic trauma. Multiple fractures are correlated with respiratory morbidity, multisystem injury and mortality.1 Outcomes from regional anaesthesia are superior to treatment with systemic opioids.2 This includes reduced pulmonary morbidity and enhanced analgesia. Improved pulmonary function reduces the incidence of pneumonia, days of ventilation, and mortality; particularly in those sustaining five or more rib fractures.3Operative rib fixation for such injuries can be technically challenging and has itu2019s detractors. However, the 2010 NICE guidelines recognise consistent efficacy in well selected patients with massive chest wall injuries.4NHS England set quality indicators for the management of major chest wall injuries and include early regional analgesia as a key indicator. We present a case of co-ordinated regional anaesthesia and operative fixation in severe chest wall trauma using our rib fracture pathway.CaseA 37-year-old man was admitted to our hospital from a regional trauma unit after sustaining significant thoracic and abdominal injuries during a car accident. CT imaging showed fractures of right posterior ribs from T3-11, left first rib fracture with brachial plexopathy, haemopneumothorax (managed with a surgical chest drain) and a grade 3 liver laceration. He was transferred to level 2 care but developed respiratory failure and reported increasing pain despite parenteral opiates. Anaesthetic review was requested and a thoracic epidural was inserted immediately. CT images were reviewed and used to measure the distance between skin and epidural space, providing depth guidance. The epidural was placed at T5-6 using a paramedian approach, with loss of resistance at 13.5cm. It was loaded with 20mls 0.25% levobupivicaine and low dose infusion of 10-15mls/hr 0.1% bupivocaine started. Epidural analgesia reduced pain scores from u2018severeu2019 to u2018mildu2019, allowed sleep, reduced opiate consumption and avoided intubation. The following morning he underwent rib fixation surgery under general anaesthesia with fixation of five posterior fractures. He was extubated immediately afterwards. Thoracic epidural remained his primary mode of analgesia both intraoperatively and until five days post op. He made excellent progress in HDU, required minimal respiratory support and mobilised independently with ongoing epidural anaesthesia one day post injury. He was discharged to level 1 care four days post injury.DiscussionThis patient suffered a very significant chest wall injury. Such injuries compromise respiratory mechanics, produce significant parenchymal contusions and cause extreme pain. Our experience suggests this often results in mechanical ventilation and prolonged stay in critical care. We avoided mechanical ventilation, and itu2019s associated morbidity, entirely in this case. Early identification and multidisciplinary input resulted in effective regional anaesthesia and identification for rib fixationWe believe in utilising trauma CT imaging to help aid appropriate placement of epidural.Epidural analgesia provided perioperative analgesia sufficient to allow extubation following rib fixation and rehabilitation far earlier than would have otherwise been possible.Conclusion This case demonstrates how a co-ordinated pathway of early regional anaesthesia combined with operative fixation can dramatically reduce morbidity in massive chest wall trauma. It also demonstrates the benefits of co-ordinated care and implementation of a rib fracture pathway.References1. Malekpour M, Hashmi A, Dove J et al. Analgesic Choice in Management of Rib Fractures: Paravertebral Block or Epidural Analgesia? Trauma. 2017;124:6.2. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136:426u2013430.3. Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138:717u2013723.4. National Institute of Health and Clinical Excellence. Stabilising a flail chest wall with metal reinforcements. 2010. Available at: https://www.nice.org.uk/guidance/ipg361/informationforpublic.

With trips to New York, Paris, London, and Rome under their belts, Dodsworth and the duck head for Japan: “The plane glided over Mount Fuji. Tokyo sparkled in the distance. Dodsworth was a little nervous.” Dodsworth has good reason to be nervous—the duck bumps into a rickshaw, falls into a koi pond (he can’t swim), and knocks over a tray of wagashi! Readers will love the slapstick humor and the odd-couple friendship between Dodsworth and the duck. Four engaging chapters of short sentences, clean design, and gem-like little paintings of the Land of the Rising Sun make it easy for early readers to enjoy the journey.

When Dodsworth and the duck vacation in Paris, they have a grand time despite running out of money and accidentally riding their bicycles in the Tour de France.

With trips to New York, Paris, and London under their belts, it’s now time for Dodsworth and the duck to visit Rome! From throwing coins into the Trevi Fountain to winning a pizza-dough-throwing contest to looking up at the Sistine Chapel ceiling, Dodsworth and his misbehaving duck take a tour of their oldest city yet. With Tim Egan’s snappy words and playful illustrations, it will surely be a spaghetti-twirling sight to see. Ciao!

Dodsworth and his duck have just arrived in London via hot air balloon. There is so much to see Double-decker buses Palaces Fog But a crowded bus stop leads to a hilarious case of mistaken identity and . . . a lost duck. Time to call in Scotland Yard?

Dodsworth wanted adventure. He wanted to see the world. He especially wanted to visit New York City. What he didn’t want was to be joined by a duck. A crazy duck. A duck that misbehaves. Young readers will laugh out loud at the duck’s silly antics as Dodsworth has the unexpected adventure of his life in the Big Apple . . . and beyond.

“Try to do as little as possible.” This was Dodsworth’s motto. One morning, on his daily trip to the junkyard, he discovers a pink refrigerator. There’s not much to say about a pink refrigerator, except this one had a note on it. The note said, “Paint pictures.” And so Dodsworth did. The next day, a new note appeared on the pink refrigerator. And the day after that, and the day after that. Dodsworth liked doing as little as possible. But the pink refrigerator had big plans for him . . .

"En faire le moins possible", telle est la devise d''Emile. Jusqu''au jour où il découvre, oublié dans une décharge, un vieux frigidaire rose décidément bien mystérieux...

Farmer Fred never smiled much. “Farmin’ is serious business,” he’d say. “Nothin’ funny about corn.” And so life on his farm was pretty serious. None of the animals laughed or even smiled. But everyone has to laugh sometimes, including Farmer Fed. The animals try everything to get him to smile: dancing by the light of the moon in Farmer Fred’s clothes, singing chickens, sheep disguised in sunglasses and mustaches. Nothing works and finally the animals decide to leave Serious Farm in search of a more cheerful place to chuckle and graze. Will the animals find a livelier home, and will Farmer Fred ever lighten up?

Sam and Jackson both agreed: nothing beat baseball. The crowds cheering, the bright green grass, the tasty roasted peanuts. Sam was an amazing athlete—very strong and fast, a big-leaguer in the making. Jackson, on the other hand, was not very strong or very fast at all. He could throw very far, but that was about it. When Sam makes the team and Jackson doesn’t, he misses having Jackson there on the field with him. And then he sees a poster . . . Tim Egan has crafted a quirky tale of friendship and loyalty, complete with a late-inning nail biter that will keep baseball fans on the edge of their seats!

Cardigan the moose was new in town. When Mrs. Brown''s fresh apple pie goes missing, witnesses come forward to place Cardigan at the scene of the crime. Finding himself on trial, Cardigan insists to judge and jury that he didn''t take the pie - he just wanted to smell it. No one believes him. But despite his assurances, he can''t explain what happened to the pie, either . . . or can he?

On a dark and scary Halloween night, Sheldon the short-order pig is out looking for work when his car breaks down. Gathering up his courage, he approaches an ominous-looking mansion and enters the twisted world of Dr. Edmund Vermin! Will poor Sheldon escape or be forever trapped in Dr. Vermin’s laboratory? Things aren’t what they seem in Tim Egan’s latest zany tale of ravishing wolves, giant pigs and . . . horseradish!

The Rogues, a band of mischievous young animals, are transformed into real crooks when they get involved with Vincent the goat and an innocent-looking little old sheep lady. Reprint.

Jealous of the highly talented dog Marley, Preston the bear spreads a rumor that the dog is a wizard.

" Au départ, nous n''étions pas des voyous. Nous formions simplement une petite bande de mauvais joueurs de bowling. Un soir, après avoir perdu la partie une fois de plus, nous avons eu l''idée la plus stupide de notre vie. Ce fut notre première erreur. Et, malheureusement pour nous, ce ne fut pas la dernière... Voici notre histoire. "

Bennett Gibbons is a very fortunate calf. His parents are prominent members of their herd and noted socialites. They live in a beautiful apartment and give Bennett everything he could want. Indeed, young Bennett is the luckiest little calf in the neighborhood. Problem is, he''s the only little calf in the neighborhood. Bennett is happy to become friends with Webster, a young pig who lives next door. But when his parents forbid the friendship Bennett runs away, and his parents soon learn the value of a good friend.

Le café de Bill est interdit aux tigres. Pourtant, un vendredi soir, trois grands tigres très furieux décident d''y entrer pour dîner. Les soufflés au chocolat commencent vite à voler. Comment la bagarre va-t-elle se terminer ? Cette histoire, écrite et illustrée par Tim Egan, raconte avec humour qu''on peut toujours s''entendre malgré ses différences et changer d''avis quand on s''est trompé.

Quand Arthur Lebœuf rencontre Fred Porceau, il devient tout de suite son ami. Mais les parents d''Arthur n''acceptent pas qu''un petit veau comme lui ait pour ami un petit cochon. Vont-ils changer d''avis ? Cette histoire drôle et émouvante, écrite et illustrée par Tim Egan, raconte comment l''amitié et la générosité peuvent triompher de bien des préjugés.