Adding YouTube videos to your Powerpoint lectures

A picture is worth a 1,000 words.

If this is true, then a video is worth 10,000 words.

This is why adding videos or dynamic images to your Powerpoint lectures is key, if you can find one to illustrate your teaching point. However, it takes a mini-lifetime to create a polished video. More likely you will find one already done on YouTube.

The problem in running online YouTube videos during your talk is that internet connection may not be reliable. I've given talks at ACEP, SAEM, CORD, and AAEM, and it is a hassle to get internet. It is an added cost and frankly, I don't want to have to rely on something out of my control to make my videos run.

My solution?

I download relevant YouTube videos onto my hard drive and insert them into my Powerpoint slides. Presumably if they are on YouTube, I won't be infringing on any copyright laws, especially because this is for non-commercial and pure educational purposes.

I did this most recently for last month's 2nd annual Trauma Intensive Care Symposium. For my talk, I downloaded a video of a Glidescope endotracheal intubation (which I used in yesterday's blog) and various dynamic ultrasound videos of positive FAST exams.

How do you download YouTube videos?
There are multitude of ways and most of them are free. For me, the most simple site is KeepVid. (I have no financial ties.) It's free. Simply find the URL address of the YouTube video you want, and paste the address into the blue bar. Click "download".


You can download in .flv format (for Flash) or .mp4 format. Macintosh powerpoint files will play mp4 videos. I'm not sure about PC powerpoints. Anyone know?

Happy downloading. Comments welcome.

Article review: Glidescope success in difficult airway simulation

Video laryngoscopy using Glidescope
(fast forward ahead to 2:20-3:08 segment)

Since our department got a Glidescope, it has rapidly become a go-to difficult airway adjunct when intubating patients in the ED. Note: I have no financial ties to Glidescope.

What's the best way to train residents in this new technique?

Personally, I think if there were a Wii game option, it would open up new doors for medical procedural education. Who knows anyone at Electronic Arts or another major software company?

This education article is a head-to-head comparison between video laryngoscopy (VL) versus direct laryngoscopy (DL) in a difficult airway simulation model. In this prospective, convenience sample of EM attendings and residents who were all novice operators of VL, the subjects were asked intubate 3 types of mannequin scenarios using a Macintosh curve laryngoscope for DL and a Glidescope for VL.

• Normal airway
• Decreased neck mobility
• Tongue edema

The subjects were timed for the following critical actions:

• Time to visualization of vocal cords
• Time to endotracheal tube through the vocal cords

Other outcome measures included:

• Grading of glottic view at time of intubation using the Cormack Lehane classification (Grade I: most of glottis seen; Grade II: only posterior portion of glottis can be seen; Grade III: only epiglottis may be seen (none of glottis seen); Grade IV: neither epiglottis nor glottis can be seen
• Intubation success
  

Cormack Lehane classification

Results

• Time to intubation for a mannequin with a NORMAL AIRWAY and DECREASED NECK MOBILITY actually was statistically faster with DL using a Macintosh blade by 9.4 and 16.1 seconds, respectively.
• Time to visualization of vocal cords for mannequin with TONGUE EDEMA was much faster for VL compared to DL by 89 seconds.
• The success rate of intubation for a mannequin with TONGUE edema was higher for VL compared to DL (83% vs 23%).
• In all scenarios, VL allowed for a better Cormack-Lehane view of the glottic opening compared to DL.
  

My thoughts
So why didn't the consistently better Cormack-Lehane view of the glottic opening with VL correlate with a faster intubation time for mannequins with a normal airway and decreased neck mobility? Why was DL faster in these cases?

Consistent with my experience and the literature, it takes some practice and learning to bend the endotracheal tube's stylet into a sharp enough 60-degree angle. In our ED, we use stylets specifically built for the Glidescope. These stylets are more rigid than the typical stylet and are bent at a sharp angle to allow the endotracheal tube to reach a more anterior glottic opening, if needed.

This study was impressive in that novice VL users only needed a simple 10-minute training session to demonstrate a significant difference in intubation success rate for difficult airway scenarios, such as tongue edema. There are obvious study limitations (eg. mannequins may not simulate real-life difficult-airway scenarios, the order of scenarios was not randomized per subject, and there were no control subjects).

Still, I'm a huge fan of video laryngoscopy. Even if it performed the same as DL, it adds tremendous value to academic ED's because faculty can now see what is going on and give real-time feedback to residents performing intubations.


Question:
Does anyone use video laryngoscopy? Any words of advice or thoughts? Please comment.



Reference
Narang AT, Oldeg PF, Medzon R, et al. Comparison of intubation success of video laryngoscopy versus direct laryngoscopy in the difficult airway using high-fidelity simulation. Sim Healthcare 2009; 4:160–5.

Paucis Verbis card: Pediatric blunt head injury

In this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is Pediatric Blunt Head Trauma .

This a particularly relevant topic given the recent press and discussions about CT irradiation and the cancer risk especially in pediatric patients. It's also relevant since Dr. Nate Kuppermann (UC Davis) just gave Grand Rounds at our UCSF-SFGH EM residency program. He first-authored a landmark 2009 Lancet article on minor head injury in kids.

Here's my back-of-the room view of the great talk.

Feel free to download this card and print on a 4'' x 6'' index card...

[MS Word] [PDF]

Reference
Kuppermann N et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.

See other Paucis Verbis cards.

Evernote: Redefining my organizational thinking

Evernote

Welcome to the age of cloud computing. This means that data files can be stored online rather than traditionally on your laptop or desktop. This allows you to access it via your laptop, any computer with web browser, or your peripheral device (in my case- the iPhone). The benefit is that you don't have multiple copies of outdated files floating around. The updated files get sync'd to the web and all your platforms as soon as access is available.

I have never been a a huge fan of organizers because it ended up being more work to keep things organized in that system or structure. This was true until four months ago when I started using Evernote. I use this FREE application almost on a daily basis.

It's a simple concept which is great in its simplicity. Here is my set-up. I use Evernote in primarily 2 locations: laptop and iPhone.

Laptop

• My Macintosh has the desktop version of Evernote. In the left column, there are a list of tags which I attach to some of my Notes. You can search by tags if needed. The middle column has the titles of all my "Notes". The right column displays the contents of the highlighted note.
  
• The most common note that I access is my To-Do list. Now I can check it on the go or on the laptop. It's always synchronized up.
  
• I have the UCSF Yellow Shuttle schedule for me to get to conference and back.
  

• A great feature of the Firefox browser is that it has a free Evernote extension which allows you to "clip" anything on the screen you'd like. It automatically imports the current website's content directly into a new Evernote note. Just click the Elephant icon in the menu bar (red arrow in image above). For example, this has been invaluable in recording the monthly ED schedule at work. Our schedules are posted through Tangiers (a web scheduling program) and it's hard to download it into a nicely formatted PDF. Here's how the schedule looks on Evernote with just one click of the button.
  

iPhone

• On my iPhone, I now can access everything that I just wrote on my laptop. It works similar to the desktop version.

• One unique option that's not available for Evernote on the desktop is the GPS feature of the iPhone. If you create a note on the iPhone, it will automatically capture information about where you made the note. So, I've heard of people taking a picture of their car at the airport long-term parking lot. If you hit "info", it'll show you where you created the note on a map! It's a sure-fire way to not lose your car in a large parking lot (reminds me of a Seinfeld episode).
  

• As an example of the GPS feature, I took an iPhone photo of a sketch yesterday on my office wall. In the Note Info page, you can see that it gives my location as San Francisco, which you can see on the map as a red dot.

Oh, and did I mention that this was free? Thought I would share my newest technology discovery. I didn't believe it at first, but it has helped me maintain an active to-do list and some organizational structure for work.

Trick of the Trade: Preventing tissue adhesive seepage

As great as tissue adhesives are in wound closure, they come with some risk. For instance, liquid adhesives, such as Dermabond, can "run" and contact undesired areas such as eyelid margins. Careful application of tissue adhesives is critical.

How can you minimize the amount of seepage of tissue adhesive to undesired areas?

Trick of the trade:
Create an impermeable tape barrier

I already mentioned this in an earlier post in July, but I now have more experience with this technique. Here are some recent photos of this trick in action.

• Cut out a circle from a transparent tape adhesive. In this case, I used a transparent Tegaderm which can be found with peripheral or central line IV kits.

• Adhere the tape to the patient's skin primarily along the circular edge to prevent glue seepage under the tape. You don't need to stick the ENTIRE transparent tape to the patient, unless you want to pull off some eyebrow and eyelid lashes!
  

• Apply the tissue adhesive glue over the wound while ensuring that the wound edges are closely approximated. Excess glue will run off onto the tape. You only need to wait a few seconds after glue application before peeling the tape off.

This idea was contributed by Dr. Hagop Afarian (UCSF-Fresno).

Thanks also to my Visual Aid Project photographer, Lourdes Adame, who photographed and consented the patient's father for these photos. Her speaking fluent Spanish made them feel at ease and understand that we were photographing for educational purposes.

Work in progress: Advanced degrees for emergency physicians

I thought getting a MD degree was a big achievement... until I see all these physicians with dual training in EM/IM and those with various advanced degrees, such as RDMS (ultrasound certification), Masters in Education, MPHs, and PhDs. I feel so plain.


A friend and colleague of mine Dr. Chad Kessler (Associate Program Director at the EM/IM Residency program at University of Illinois-Chicago) recently published about career outcomes and job satisfaction for those who did a combined residency in EM and Internal Medicine. (Kessler CK, Stallings LA, Gonzalez AA, Templeman TA. Acad Emerg Med 2009; 16:894–9.)

(click to enlarge abstract)

Chad and I are starting to brainstorm about how we could determine how many U.S. academic emergency physicians have advanced degrees. I get a sense that more and more EM residents and faculty have advanced degrees. What are people doing with these degrees (besides having an alphabet soup after their name on a hospital badge)?

We will be starting to scour the department and residency websites to start our initial database. If you are from an EM department or residency, please feel free to email me the advanced training info on your faculty. Any help would be much appreciated!

Article review: Long axis view for IJ line placement

Looking for the right IJ vein under ultrasound

As bedside ultrasonography is becoming a staple in central line placement (especially of internal jugular lines), emergency physicians now can minimize complications, such as carotid artery puncture and a pneumothorax. Traditionally, the US probe is positioned along the short-axis of the IJ during the procedure (see above). The resulting image shows two circular structures, which are the carotid artery and IJ (see below image).


In an article published in Critical Care Medicine, the authors challenge providers to use the long-axis, rather than the short-axis view.

Why, you ask? Because of the risk of posterior wall puncture of the IJ vein.


QUESTION
Does anyone use the long axis view for IJ vein cannulation? I'd love to hear your thoughts.



Study design
Using a life-like human torso mannequin, 25 EM residents placed ultrasound-guided IJ lines. All had attended a 3-hour didactic and hands-on session on the procedure. Also all had placed ultrasound-guided IJ lines previously in actual patients.

The residents used the short-axis U/S view of the IJ. During this procedure, one investigator tracked the resident's needle using an endocavitary probe just inferior to the vascular probe. The convex shape of the endocavitary probe made it possible to visualize the soft tissue directly under the vascular probe.

The residents were asked to stop the procedure once they felt that the needle tip was in the middle of the IJ vein. The guidewire was not introduced.

Mannequin IJ-line placement using the vascular probe.
The endocavitary probe tracked the needle course.
(image from Crit Care Med article)


IJ vein in long view with needle puncturing lumen

Main outcome measure
The incidence of posterior wall penetration, as defined as a 2nd venous wall penetration with an antecedent anterior wall penetration by the needle and needle shaft.

Results
At first glance, the study results were very surprising. I have always had great results with the short-axis view of the IJ for line placement.

• 16 of 25 residents (64%) accidentally penetrated the posterior wall while attempting to cannulate the IJ vein with a needle.
• For 6 of 25 residents (24%), the final position of the needle tip was posterior to the venous lumen.
• For 5 of 25 residents (20%), the final position of the needle tip was in the carotid artery
• More advanced training (r=-0.41) and degree of experience with ultrasound guided central lines (r=-0.54) were inversely correlated with posterior vein wall penetration.
  

Bottom line and thoughts
Overall, while this study brings up an interesting discussion about the best view for IJ line placement, I question the clinical significance of the study findings.

1. The residents were not allowed to feed a guidewire to confirm successful IJ cannulation. For the 24% of residents who had positioned the needle tip posterior to the IJ lumen, I presume that the guidewire would not have been able to feed completely, if this were an actual patient. Consequently, the resident would have re-positioned the needle.
   
2. If someone penetrated the posterior wall while trying to cannulate the IJ vein (64% incidence in this study), does this clinically matter if the needle and guidewire eventually end up in the IJ vein? I don't think so.
3. For the 20% of residents who had the needle tip in the carotid artery lumen, presumably the bright red nature or pulsatile flow of the blood return in an actual patient would have alarmed the resident (and attending!) that the needle was in the incorrect location and required repositioning.
   

While this study brings up an interesting complication of IJ line placement using the short-axis U/S view, the next step is to do this study in actual patients.

Words of caution
If you are thinking of using the long axis view of the IJ, start by finding the IJ using the short axis view. Keeping the IJ vein on the screen at all times, rotate the probe 90-degrees into the long axis view. Be sure that you are still looking at the IJ vein and not the carotid artery. Often on the long axis view, you can only see one vascular structure at a time. Be sure it's the right one!

Also with the long axis view, try to keep your needle directed within the plane of the ultrasound. The needle easily can move in and out of the plane and thus disappear from the screen.

Reference
Blaivas M, Adhikari S. An unseen danger: Frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med 2009; 37:2345–9.