Two viral videos

Here are 2 great videos that are going viral on the internet this week.

1. Abusers of the Emergency Department
The comedy TV show "Scrubs" and the Tina Fey/Sarah Palin parodies are funny, because they are sadly based on some truth. The same goes for this video.

My favorite quote is - "That was not a seizure. That was a dance move." I have heard each of these different complaints while working in the ED ... within the past week. How about you?

Working in the ED is constantly a lesson in professionalism. Hard not to keep a straight face while trying to explain your reasons for not giving them opiates or sedatives. At the same time, my devilish subconscious self is thinking- "I wish I could have those last 15 minutes back in my life."

2. Pink Glove Dance
A very cute Providence St. Vincent Hospital video supporting breast cancer awareness.

Using powerpoint to make scientific posters

In the past, I had made scientific posters using Adobe Photoshop software. The software was more complex than I needed. More recently, I have used Powerpoint to make posters. You really only need the following functionalities:

• writing text and text headers
• importing images and spreadsheets
• drawing basic shapes and arrows

Creating a customized poster size
To create the proper poster dimensions, go to the File menu and select Page Setup. Select Custom slide sizing, and enter the appropriate dimensions. In this case, I selected 50'' x 50''.


Tips:

• Be sure to follow the poster dimension criteria set by the conference that you are presenting at. I was once at a conference where the presenter couldn't hang her poster because it was too large.
• Use a white background. A colored or gradient background can turn out unpredictably at the print shop. Remember that screen image quality does not always mirror print quality.
  
• When you are all done with the poster, zoom in to 300% size to determine if the print resolution is adequate. Pay special attention to imported images.

For addition tips on making a more effective poster, go to an earlier blog post.

Trick of the Trade: Subclavian line gone north

In patients requiring central venous access, which vein do you prefer? In descending order, I prefer subclavians, internal jugulars (IJ), and then femorals.

There is increasing evidence that subclavian central venous lines are superior to femoral lines (JAMA 2001) with respect to iatrogenic infection and thrombosis rates. In 9% of subclavian lines, however, the line tip ends up in the ipsilateral IJ, instead of the superior vena cava (SVC) - see chest xray below. These lines are unusable in the long term because of the risk of cathether thrombosis in this low-flow area. The line must must be rewired.

What's a common technique to minimize this complication risk?
Insert the guidewire into the needle such that the J-tip of the wire points inferiorly. This will allow the wire to float into the SVC moreso than the IJ.

Trick of the Trade: Ambesh Maneuver
I use this trick regularly. It is a technique which I read about in the Anesthesia literature (Anesth 2002) published by Dr. Ambesh. The Ambesh Maneuver involves the simple external compression of the IJ vein during guidewire insertion.

Ambesh maneuver: Staged demo on a volunteer.
Don't worry, the needle was photoshopped to make
it look like I punctured the skin. Also in retrospect,
I would have draped more sterilely.

Put your a sterile finger at the base of the IJ in the supraclavicular fossa during guidewire insertion. The guidewire will meet resistance if it attempts to cannulate the IJ. This maneuver reduced the incidence of ipsilateral IJ cannulation from 6% (control) to 0% (Ambesh maneuver).

Faculty hero: Ernest Wang (part 1)

I've been writing several "Faculty Spotlights" to feature some really amazing EM faculty members. It has dawned on me that a much more appropriate name for the series is "Faculty Hero".

I have known Ernie Wang for many years now way back to when we were both on the SAEM Undergraduate Education Committee (which is now the CDEM Academy). I've been an admirer of all the amazing work that he's done in the past several years. In fact, there are so many things that I'd like to highlight that this post is divided into 2 parts. The second part will be posted next Tuesday.

Clinical Assistant Professor, NorthShore University HealthSystem

Academic Director, Center for Simulation Technology & Academic Research (CSTAR)
Associate Program Director, University of Chicago EM Residency

Ernie, what’s your academic niche in EM?
My main academic niche is simulation-based medical education. And I have to confess that I came about it mostly by serendipity.

My academic career was really an unplanned event and I took the "bent-arrow" route to it. I still consider myself a clinician first, an educator second, and an academician third because I really enjoy taking care of patients, doing the "work" of emergency medicine, and working side by side with residents and students in the ED. I spent my first three years working clinically exclusively. Then I was asked to be the associate medical student clerkship director, did that for two years, then took over for our site as the associate program director for the EM residency.

Somewhere about that time, I was introduced to simulation as a result of working with John Vozenilek at NorthShore. Voz invited Jim Gordon to come to NorthShore to give a grand rounds on this "new" teaching modality called "simulation" and really turned us on to the possibilities that sim could provide for our students and residents. I then went to SAEM to a simulation workshop conducted by members of the nascent SAEM simulation interest group.

I distinctly remember Steve McLaughlin giving a compelling talk about the strengths of simulation. There was a subsequent demonstration which in which I, along with several others, volunteered to be be in the hot seat. We went into the sim and proceeded to kill the patient in expert fashion. I was convinced at that point that this was going to be a cool way to teach and train.


So how are you involved with simulation now?
I have been active with the simulation lab at the Center for Simulation Technology and Academic Research (CSTAR) since 2003. As the current academic director of CSTAR, my main educational activities involve the provision of simulation-based experiential learning for medical students (originally from Northwestern University Feinberg School of Medicine and, since 2009, the University of Chicago Pritzker School of Medicine), residents, nursing, and pre-hospital providers, through our various programs at the Evanston simulation center and the Highland Park simulation center.

Our medical student program is 2-3 hour weekly simulation experience overviewing code resuscitation and management of fundamental emergent scenarios. Our resident simulation program is based on a modular curriculum consisting of procedural training, pediatric scenarios, medical and surgical scenarios, OB/GYN and trauma scenarios. We incorporate core competency learning objectives (particularly systems-based practice issues) into the cases which are often drawn from real cases in the ED.

While the medical students and resident simulation education comprises a majority of our educational programs, we are rapidly developing a robust nursing training program entitled “The First 5 Minutes” where we train nurses to recognize and provide immediate treatment for the acutely decompensated patient. The goal is to provide this program to all the medical and surgical nurses within all the NorthShore hospitals. The foci of the program involves improving situational awareness of decompensating patients, promoting effective communication, and enhancing patient safety. We have recently begun implementing programs to train the Lake County Health Department medical staff on the management of acute emergencies in the office setting. In addition we have initiated outreach programs with our local high school, Highland Park Hospital, providing simulation based medical exposure to Hispanic students to promote careers in the medical field.

Wow Ernie, I had no idea that you were teaching so many different learners! You also have many "virtual learners". I've seen your simulation-based educational videos. They are really professional-looking and extremely valuable teaching tools.
Our academic productivity at CSTAR has been a fruitful collaboration. Over the past five years, we have collectively published 24 peer-reviewed original works in the field of simulation-based education. The variety really has made it interesting - we have done some original research, participated in multiple consensus publications, reported our innovations in curriculum design and task trainer product development, and created a collection of procedural videos. We have three more publications that have been accepted and several more in process.

My personal work has focused on development of procedural expertise, simulation case development, curriculum design, and systems-based practice education with simulation.

Ernie giving an overview of simulation to incoming
medical students from University of Chicago.

You've definitely carved a huge academic niche in simulation and technology.
Yes, and I hope I can serve as an example of someone who took a non-traditional approach to academics and has been able to achieve my goals and have fun doing it. You don't always have to go straight into it right out of residency or work at the big University hospital to be academically productive.

Academia is a wonderful way to supplement your clinical career. It keeps you interested, it keeps you sharp, and it can provide more job satisfaction that will likely prolong your career. Academia is meaningful to me primarily in the context of relationships, mentoring, doing projects with others. You can't do it alone. You have to rely on and acknowledge those that helped you get where you are and do your part by passing the passion and lessons along to those who will follow you in the next generation.

I can't agree with you more, Ernie. We need more inspiring leaders in academics like yourself. Keep up the amazing work.

Article Review: Hidden cost of reducing resident duty hours

Patient care versus education

This is the tug-of-war struggle that residency programs constantly grapple with. Residents work in an apprenticeship model where they are both patient providers and learners. Both are critical in residency training, but they sometimes negatively impact each other. For instance, EM residents hand-off their patients to covering residents while attending their weekly conference classes. In contrast, residents may skip that day's board teaching rounds to manage an acutely decompensating patient.

In 2003, the Institute of Medicine (IOM) set the 80-hour workweek standard for all residency programs. More recently this year, the IOM proposed additional duty hour restrictions:

• When on call, the maximum on-call period is 30 hours. There also needs to be a 5-hour continuous sleep period during this time such that the resident's maximum awake period is 16 hours.
  
• Night float must not exceed four consecutive nights and must be followed by a minimum of 48 continuous off-duty hours after three or four consecutive nights.
• Both internal and external moonlighting should be counted against the 80-hour weekly limit. Currently moonlighting is not counted.
  
• The maximum in-hospital, on-call frequency should be every third night without averaging. As an intern on the orthopedics team, I remember taking q2 night calls, intermixed with some q4 and q5 night calls so that everyone can get a weekend off. This would be eliminated with this new rule.
• The minimum time off between scheduled shifts should be 10 hours after a day shift, 12 hours after a night shift, and 14 hours after any extended duty period of 30 hours.
• Mandatory time off duty should increase to 5 days off per month: one day off per week, without averaging, and one 48-hour period off per month.

On surface level, the IOM logic makes sense.
Give the residents more rest from patient care responsibilities. This will give us better learners.

But let's look deeper.
This Annals of Emerg Med opinion article discusses the faulty logic of these proposed duty hour changes.

• When residents graduate and practice as attending physicians, they may be asked to work more consecutive hours or more frequent shifts than they have ever worked during residency. Is this right?
• Having more hours off (eg. 5-hour nap), days off, and work hour restrictions will result in more patient hand-offs, which are known to increase patient care errors. It's too bad that patients change their clinical course dynamically and don't follow the work clock.
  
• Limiting the number of consecutive night shifts will result in more circadian dysrhythmias.
• Every specialty is different in training requirements, learning environments, and patient population. While some specialties (i.e. surgical programs) might benefit from a more structured reduction in work hours, imposing a blanket statement on all programs seems impractical and short-sighted.
• If residents work fewer hours overall, residency programs should be extended by at least another year of training. Experiential learning is critical in preparing a resident for clinical practice as an attending physician. You really never want to hear your doctor saying, "Hmm, I've never seen that before."
• With all the shorter work hours, hospitals will need to hire more attending physicians and mid-level providers to cover the gaps in patient care.
  

The Residency Review Committee for EM, ACEP, and EMRA have responded with a joint letter applauding the philosophy of optimizing resident learning and patient safety. They, however, opposed the implementation proposal for stricter duty hour rules. I totally agree.

While we're on the topic of duty hours,
I think we should also address
faculty duty hours too!

Reference
Millard WB. For Whom the Bell Commission Tolls: Unintended Effects of Limiting Residents' Hours. Ann Emerg Med. Oct 2009; 54(4):A25-A29.

Hot off the press: Free MP3s on Amazon

Are you like me and need catchy tunes
playing in the background to
get more work done on the computer?

I just discovered that Amazon is giving out $3 worth of free MP3s. The deal expires November 30.

Instructions:

1. Click on this Amazon link.
2. Be sure to enter the promotional code (MP34FREE) in the pop-up window before actually downloading the music.
3. Download MP3s that you want.

Enjoy!

Happy Turkey Day

Get off the computer and have a fun, belly-busting Turkey Day.