Faculty spotlight: Dr. Ghazala Sharieff

It's not every day that you get to meet and hang out with a fun, funny, humble, spirited, and super-smart person. I first got to know Dr. Ghazala Sharieff on the lecture circuit. She's one of the major go-to speakers for anything related to pediatric EM. When I'm stuck in a dilemma about a pediatric patient, I think - WWGD? What would Ghazala do?

Also if you're ever walking with her at an EM conference, you can't really get more than 10 feet before being mobbed by people wanting to say hi to her. So I wanted to introduce you to a good friend and genuine rock-star in medicine.

Dr. Ghazala Sharieff Division Director of Rady Children's Hospital Emergency Care Center Associate Clinical Professor, UCSD

Undergraduate: Univ of Michigan
Medical school: Michigan State
EM Residency: Stanford-Kaiser
Pediatric EM Fellowship: Children's San Diego

Ghazala, what's your academic niche and who were your mentors? My academic niche is in national and international speaking. I fell into this with the help of Mel Herbert, Larry Satkowiak and Mike Gerardi. I was pretty aggressive about being on the lecture circuit.

You can check out free previews of her talks from various conferences from CMEdownload.com (View previews)

What projects are you working on? I have a few projects underway. I'm the pediatrics section editor for Harwood Nuss and just published a textbook on neonatal and infant emergencies, by Cambridge. It came out last November!

I'm also working on some research projects with my fellows.

• A study on single dose decadron vs day 1 and day 3 decadron for asthma.
• A study on the use of a rapid medical assessment program in decreasing left without being seen rates in a pediatrics ED.
• A study on ketamine vs ketamine plus propofol for sedation in the pediatric ED

Article review: Teaching when time is limited

A 2008 British Medical Journal article focused on practical tips and approaches to teaching in busy environments. This is especially relevant to those of us in Emergency Medicine. We are balancing trying to take care of patients, teach eager learners, and troubleshoot logistical hurdles while trying to find 30 seconds to eat dinner or have a bathroom break! I wonder how many emergency physicians have hydronephrosis at any given time on a shift... Someone should do a study.

Basically, bedside teaching can be extremely high-yield to the learner and can be done concisely. The question is how and when. The general framework is comprised of 3 steps:

Identify the learner needs.
Teach rapidly.
Provide feedback.

Identify the learner needs. When lecturing in a large-group setting, you need to know your audience. Similarly with bedside teaching, you need to know the learner's knowledge base. At the beginning of my shift, my trick is to ask the learner what (s)he wants to learn or work that day. I then have an invested learner and know what areas to focus on.

Teach rapidly. There are several models for teaching rapidly, but the one I find most useful in the ED is the "one-minute preceptor" model. This works especially well after the learner presents a new patient to you:

1. Ask the learner what (s)he thinks is going on with the patient. Avoid presenting your own assessment too early.
2. Ask the learner why (s)he thinks that and solicit for alternative explanations.
3. Teach a short general principle. (eg. 10% of patients with kidney stones don't have microscopic hematuria.)
4. Provide positive feedback on something done correctly.
5. Provide 1 concrete constructive tip for improvement. (eg. Next time, remember to perform an abdominal exam in patients with flank pain to check for a pulsatile mass.)

Other models are presented, such as the Aunt Minnie model, SNAPPS model, "activated" demonstrations, and case presentations at the bedside. I find the one-minute preceptor works best for me.

Provide feedback. This is crucial in teaching. It can be subtle to the learner, so I preface with "Just a little feedback...". For example: "Just a little feedback, your presentation on this renal colic patient was really well done and, although unlikely, I'd just consider AAA in your exam and differential diagnosis in the future."

Reference:
Irby DM, Wilkerson LA. Teaching when time is limited. BMJ 2008; 336(7640): 384-7.

Hot off the press: New iPhone app on ultrasound

My friend and colleague at USC, Dr. Diku Mandavia, alerted me about a new iPhone app that just came out called SonoAccess, developed by Sonosite. This free app has stock photos of images, in addition to video lectures of common applications such as the FAST, aorta, pelvic, gallbladder, and many other scans. Check it out!

If you want to see movie-star-in-the-making Diku in action, check out the video on measuring the common bile duct (CBD) for gallbladder scans. Nice, Diku, nice. If only CBD's were THAT easy to find. It's my Achilles heal of ultrasonography. It always takes me forever to find the CBD, such that patients probably are wondering if (A) I know what I am doing or (B) I have found something really abnormal and looking at it more carefully. I'm going to need a private tutorial with Diku.

Check out the company's video introducing the product. I have no affiliation with the company.



If you have used this application, what do you think of it?

Humorous distillation of specialty personalities

If only I had this flowchart when I was a first-year medical student! I too have always felt that emergency physicians have a little baseline crazy in them to be happy and successful in the specialty.

This diagram has been floating around the web for years now, and I wanted to share with you. It's a humorous (partly because there's some truth to it) decision tree on how to choose your medical specialty. Did you decide upon the right field?

I use this in some of my medical school/ EM Interest Group talks just to break the ice. We talk about stereotypes and how you don't necessary have to fit into them. For instance, I'd rather be a couch potato than scale mountains and swim with sharks. Feel free to use, if you advise medical students!

Tricks of the Trade: Tissue adhesives and tegaderm

Photo courtesy of Dr. Hagop Afarian (UCSF-Fresno)

Tissue adhesives for wound closure often seem to intentionally make a bee-line straight for high-risk areas such as the eye. To avoid inadvertent application of the tissue adhesive, Dr. Hagop Afarian (UCSF-Fresno) utilizes a transparent tegaderm tape with an oval cut out of the center to provide a protective barrier. Immediately after application of the tissue adhesive, the tegaderm can be carefully peeled off to reveal a still-drying, well-circumscribed aliquot of glue over the wound. Be sure that the wound is dry, and the edges are well-apposed prior to tissue adhesive application.

This clinical pearl was highlighted in one of the 2008 ACEP News Tricks of the Trade columns which I co-authored with Hagop.

Question for you: What tricks of the trade do you have for keeping tissue adhesives away from high-risk areas during wound closure?

Faculty spotlight: Dr. Renee Hsia

There are so many interesting and inspiring EM faculty and none more so than in our own department at San Francisco General Hospital. Dr. Renee Hsia is a rising superstar in our department who has received numerous fancy awards and grants including the prestigious Robert Wood Johnson Faculty Scholar award. She makes me feel small, insignificant, and uncultured. For instance, I thought Eritrea was a rash. Anyway, read below to see what I mean. Good thing I can at least beat her in foosball.

Renee Hsia, MD MPH

Medical school: Harvard
Grad school: London School of Economics & School of Hygiene and Tropical Med
Residency: Stanford-Kaiser

What is your academic niche and how did you decide upon it?
I am absolutely passionate about the clinical practice of EM and, without a doubt, being in the emergency department forms not only the basis of my work, but also provides the impetus behind my research. Beyond the clinical practice, I spend a lot of time thinking about the development of health systems and its impact on populations, both domestically and globally. I can pinpoint when this broader perspective came alive to me to a brief period of my life when I lived in South Africa for six months. As a “colored” in that society, I realized on a very personal level that systems matter, and that almost all of the disparities I saw — and experienced — stemmed from policies that were intentionally and systematically designed to not only create, but also maintain, these injustices.

After that, I spent small bits of my life in different parts of the world between and after medical school, mainly in sub-Saharan Africa, from Rwanda to Senegal to Eritrea. After some pretty wild experiences (spanning the spectrum of becoming delirious with malarial fevers to ducking gunfire from the Congo), I decided to commit to developing my interests in health policy and finance at the London School of Economics and the London School of Hygiene and Tropical Medicine.

Since then, I’ve spent my energy in better understanding the health care systems and impacts of policies on underserved populations in domestic and international contexts. Some people wonder if doing domestic and global health work is contradictory, but I find that they mutually enrich my understanding of the other. Especially at San Francisco General, which is the county hospital for SF and where the majority of homeless patients receive their care, I find striking parallels in the barriers that patients who have few resources make, whether it be in the U.S. or in Africa. Examples range from patients who must decide whether to forgo medicine for food, where they should seek care, and how the context influences their behavior.

So who were your mentors?
Tough question; I think “mentorship” can range from those who, in the traditional sense of the word, teach you more in a certain discipline, to those who, on a broader scale, inspire you to be who you were to created to be. I’ve had incredible teachers who have been incredible mentors in both meanings of the word. But I’ve also been blessed to be challenged by people I wouldn’t necessarily think could or would lead me to think more deeply about my place in life. Many of the larger lessons I’ve been learning along the way have been taught to me by children.

For example, I remember once on a mission to Haiti, I was in a Jeep that was carrying bags of rice to remote and impoverished areas, and as soon as we drove up to the village, the Jeep was almost turned over by totally famished children who were overjoyed at the sight of the next food provision. There was one child who held back from the crowd and came up to me, rather than the bags of food, and noticed at the band-aid on my finger (covering a papercut) and asked, “Ca te fait mal?” (“Does that hurt you?”). The fact that he could, despite his own needs, actually care about mine, absolutely blew me away. I still am hoping to become more like him.

What are you currently working on?
A million things, but I’ll name a few!

One of my projects is looking at whether emergency services are less available to underserved populations – meaning, those who are poor, have no insurance, or are minority. Since health care in this country is largely driven by market forces, there are inevitable effects of this choice on certain populations. Practically, for example, many ED physicians and health care administrators would say that areas with high proportions of the uninsured will have fewer emergency services since hospitals in these areas can’t afford to keep these services open. And while anecdotally we think this is true, there’s been relatively little research to actually provide evidence for this. I’m working on a few projects that show that this is indeed happening in emergency departments and trauma centers.

In global health, there are a few projects in which I’m involved to shed more light on the need for emergency and surgical services abroad. While these have traditionally been thought of as “high-cost” interventions, there are actually many emergency and surgical conditions that are amenable to low-cost, curative care. How can we define these needs? How can we determine which interventions are cost-effective? How can we address these problems with practical solutions alongside governments who want to provide these services? There are a few collaborations through the Global Health Sciences at UCSF that I’ve been developing, specifically in Uganda and Niger, and perhaps Rwanda in the near future.

I think the underlying question behind my work, both on a clinical level and a research level, would be, “How do we treat people with dignity?” This can come in the form of treating patients in the ED with respect and caring for their needs as best as we can, as well as providing on a systems-level the resources they need to have physical health to be who, as I said earlier, they were created to be.

Wow. A perfect example that clearly one person CAN make a difference.

Article review: Interruptions during oral case presentations

Do you remember when you were a medical student and had to present patient cases to the ED attending? How often did they interrupt your presentation, and did this affect your learning experience?

These were the questions that the following article by Dr. Rachel Chin (a super-mom colleague of mine at SF General) and Dr. Glen Yang answered in her 2007 publication in the Academic Emergency Medicine journal. Pubmed citation

This article has changed how I now listen to presentations.

Briefly, in this prospective study at SF General, one medical student observed 196 oral case presentations (OCP) in a convenience sampling of all ED shifts. The mean duration of an OCP was 3.30 minutes (± 1.85 min) for a range of trainees including students through PGY-3 residents. The medical student OCPs averaged a little over 4 minutes, while PGY-3 OCPs averaged about 1 minute. The average frequency of interruptions, however, was fairly stable at around 0.75 interruptions per minute, or 1 interruption every 80 seconds.

Other findings included:
1. Assessment and plans for the patient were prematurely provided to the trainee in 57% of medical student OCPs versus only 10% of PGY-3 resident OCPs.

2. In instances when OCPs were interrupted by the attending, 8.3% of the trainees felt that the interruptions were "disruptive" to the presentation. It's a small percentage, but I think we can do better -- by just saying less during the initial presentation. Less is more.

3. Despite some trainees finding the interruptions disruptive, the learning experience of the OCP was rated as 3.4 (± 1.0) on a scale of 1-5 (with 5 being the most effective) amongst all the trainees.

How has this changed my practice?

1. I make an active effort to minimize interruptions unless I just can't help myself, or the presentation is going on WAAAAY too long.

2. I refrain from providing an initial assessment and plan, especially for the medical students. Having the trainees propose an assessment and plan actually has provided me with much more insight about their knowledge base and their sense of sick vs not sick. Plus I'm often pleasantly surprised that they've thought of things that I haven't! Shh, don't tell them.

Open the education flood gates: Google Wave is coming

Get ready for the newest revolutionary product by Google, called Google Wave. It is due out in late 2009 and it's free. Brought to you by the same creative team within Google who brought us Google Maps, comments from various reviewers are:

"The platform to end all other web communication platforms"
"A new communications architecture"
"Google Wave will change education forever"
"A paradigm shifter, disruptive product, and maybe even an email killer"

What is Google Wave?
It is hard to describe and apparently is much more clear when you actually see it in action. At first glance, it looks a little like an email interface. Basically it's meant to be a real-time, all-encompassing communications platform which incorporates your email, Facebook/ Twitter/ social networks, instant messaging, blogs, and file sharing. In Google Wave, you create a "wave" and add people and documents to it. According to Google, "A wave is equal parts conversation and document, where people can communicate and work together with richly formatted text, photos, videos, maps, and more." The novelty is that this can all be done in synchronously and asynchronously.


What's so amazing about it?
Wow, it will be revolutionary. If my smart techy friends around here at Yahoo, Facebook, and FooPets are pee-in-their-pants excited, I know that Google Wave is going to take the world by storm.

Because Google Wave is focused towards real-time collaboration, interactions, and communication, its amazing features apply perfectly towards medical education.

1. Live Wiki-like functionality: Right now, I find Wikis fairly user-UNfriendly since it's hard to access and usually at a separate website location from everything else that I am working on. Google Wave has incorporated the great wiki capability of editing documents and text but in true real-time. You can edit not only your own message but ANYONE's message on the "wave". Conversations can be reorganized. Much easier to find and read a group's most recent version of a write-up or list, instead of following a disjointed string of emails.

2. Wave extensions: Extensions will allow you to manage your email, projects, Facebook, Twitter, and anything online in your Google Wave account. I'm all for consolidating all of my peripheral digital applications into one central location.

3. Each "wave" can be embedded onto a website. That means that you no longer need chatrooms or forums. You can now easily share conversions with a focus group or the public in real-time. Examples include a customer service wave or an "ask the instructor" wave where the instructor, TA's, and other learners can read and respond in real-time.

4. Playback feature: I've always felt that listservs are antiquated since you usually can't find the history of discussions or prior posts. Every year, I frustratingly re-read the same posts and discussions in listservs with constantly new members. In Google Wave, you can "playback" the history of conversations and any changes in the wave. It allows the late-joiner to get up to speed quickly.

Here's the whole 80 minute Google Wave release video, if you are interested:

Opportunities to get your education studies published

Traditionally, educational innovations and studies are difficult to publish in mainstream EM journals for a multitude of reasons. Generally these studies are more difficult to implement given financial constraints, small sample sizes, and the complex nature of studying people's behavior (rather than searching databases or studying concrete clinical outcomes).

The EM specialty slowly continues to improve and overcome such methodological flaws and obstacles in educational research. Sneak peek alert: Dr. Sue Farrell (Brigham Women's Hospital) and a team of other notable EM faculty just got a publication accepted by Academic Emergency Medicine highlighting the top 2008 educational research publications in EM. It plans to be an annual series. Keep a lookout for it.

Increasingly, education is coming to the forefront of academic emergency medicine. In addition to the traditional EM journal opportunities for publication, there are places to publish education-specific studies:

1. AAMC's MedEdPortal (link)
A free peer-reviewed publication and repository service.


2. Academic EM journal- Education Supplement
Starting this year, the AEM journal, partnering with the Council of Residency Directors (CORD), will be publishing an annual supplement which will feature only high quality, education-specific articles. This will likely include publications ranging from traditional educational research articles to select education abstracts from the recent CORD meeting.


3. Academic Medicine journal (link)
The journal for the Association for American Medical Colleges (AAMC)

4. Teaching and Learning in Medicine journal (link)
For those with educational innovations, this international journal publishes twice yearly on "Really Good Stuff" in medical education. These abstract-based articles are short and easy to write up, if you have a good innovation you'd like to share.

Tricks of the Trade: 2 free iPhone apps

Blog site update: I just wanted to share how thrilled I am that we've reached over 250 hits on this site already, and that there are comments from the (in)famous Dr. Chris Fox (UC Irvine) and cutting-edge Dr. Rahul Patwari (Rush) - see the "comments" links under the posts. Let's keep the ideas coming!

Welcome to the "Tweeters" referred over from the ACEP News Twitter feed.

In a recent Tricks of the Trade article in ACEP News, Dr. Eric Silman wrote about 5 iPhone apps which are useful tools in the Emergency Department. Here is an excerpt from his article, featuring two free apps:

Epocrates (v2.1 released January 2009)

The old standby, still free and still the king. Search or browse over 3,300 prescription and OTC meds, dosing, adverse effects, interactions, and pill photos. Frequent updates keep you in the loop on new meds and changing indications. Pill ID is useful in the ED specifically when managing an overdose, a suicide attempt, or when a patient brings in a daily pill organizer with unknown medications. The “Essentials” package adds peer-reviewed disease content developed in collaboration with the British Medical Journal, references for most major lab tests, and information on hundreds of herbal supplements. The free portion is more than sufficient for the average emergency physician’s day-to-day needs.

Eye Chart (Dok, LLC. v1.1 released October 2008)
This application speaks for itself. This classic Snellen Eye chart is designed to be viewed at a distance of 4 feet, and looks sharp and bright on most iPhones. While not validated or perfect, this tool certainly is convenient in the ED where Snellen charts may be scarce or inconvenient. Coincidentally, 4 feet is beyond arms’ reach of 99.9% of grabby patients.

iPhone apps for purchase:
* The ECG Guide (QxMD Software. Released February 2009. $4.99)
* MediMath (Evan Schoenberg. v2.4 released February 2009. $4.99)
* ACLS (DoctorCalc.com. v1.1 released November 2008. $4.99)

Question for you: What medical iPhone apps do you like?
Use the comments link below.

Faculty spotlight: Dr. Rob Rogers

Over the years, I have gotten to meet lots of really inspiring and fun EM faculty across the country through random encounters. Recently, I got to hang out with Dr. Rob Rogers (Univ Maryland), sitting at a beachside bar in Barbados during the Carribean EM Congress. The picture above is what he calls his "Corona commercial" shot. We were both speakers at the conference and couldn't believe the gorgeous weather in January.

So, I wanted to introduce you to Rob - one of my all-time favorite people.

Rob Rogers, MD
Assistant Professor of Emergency Medicine and Medicine
Director of Undergraduate Medical Education
University of Maryland

Medical school training: University of Tennessee, Memphis
Residency training: University of Maryland, Combined EM/IM

Rob, what's your academic niche?
My academic niche "major" is Teaching. My "minor" is Vascular Emergencies. I have always been interested in vascular emergencies, particularly acute aortic disease and pulmonary embolism-even in medical school. I have always had a passion for teaching and consider that my main niche, if you will. Inspired by my mentor, Amal Mattu and others, I am making teaching emergency medicine my life long focus.

Who has been your mentor and what good advice have you received?
My mentor is Amal Mattu. Best pieces of advice:
1. Get a niche
2. Don't underestimate the power of sending an email to volunteer for a project. Most people will be interested in your ideas. All it takes is initiative.
3. Be reliable.
4. Just show up. Many times "just showing up" makes a tremendous difference.

What are you working on right now?

I've got many projects in the works:
1. Editor-in-chief, CDEM Medical Student Educators book
2. Teaching workshop for a Capetown South Africa conference
3. EMRAP Educators Edition podcast (www.emrapee.com)
4. Already working on plans for 2nd edition to Practical Teaching in Emergency Medicine (website with videos of teaching, etc.) - FYI, Rob is the editor-in-chief of this textbook.

What's else is new with you?
I recently traveled to the Netherlands this month and directed a workshop entitled "Teach the Teachers" (along with Amal) at the 3rd Dutch North Sea Emergency Medicine conference in the Netherlands, June 2009. Before that I gave lectures on vascular emergencies at a conference in Buenos Aires, Argentina, May 2009.

Plans for world domination?
Not sure I have any... yet.

Article review: Faculty development needs by junior EM faculty

I've navigated the academic waters of EM partly through blind luck, partly through trial and error, and partly through timely words of advice from my mentors. Finding mentorship and early faculty development opportunities was the subject of a 2007 survey study of 954 EM junior faculty performed by the American College of Emergency Physicians (ACEP). Pubmed link

Although the study had only a 25% response rate, it still illustrated the perceived needs of junior EM faculty trying to be successful in academics. Areas included education, administration, research, professional development, and academic environment. The article described that there are actually several resources available, as outlined in the supplement attached to the publication. Knowledge of available resources is crucial for medical students, residents, and faculty interested in pursuing academic EM. If you email me, I'd be happy to send a copy of the supplement to you. Michelle.Lin@emergency.ucsf.edu

According to the study, mentorship remains an area of faculty development which still needs improvement, in addition to physician wellness.

“Mentoring is a brain to pick, an ear to listen, and a push in the right direction.” - American politician John Crosby

“Do or do not... there is no try.” - Yoda

Blogs - perfect for medical education

I started this blog on life in academic emergency medicine after having read many articles about how a blog (short for "web log") is the communication and teaching tool of the future. This is an example of Web 2.0 technology.

I found a great slide set by Frank Calberg, an innovator and educator from Switzerland. Step through the following slides to read more about how blogs are great for teaching and are here to stay.

11 advantages of using a blog for teaching

View more Microsoft Word documents from Frank Calberg.

Do you know what Web 2.0 is?

Web 2.0 is here. It's time for us in academic medicine to catch up to the rest of the world. What are you doing to incorporate it into your academic life? Actually, by reading this blog, you are now part of Web 2.0 whether you knew it or not!

What is it? It is a catch-phrase describing the "next generation" of the internet with a learner-centric focus, rather than a classroom-centric focus. It's a hard concept to describe, but I best grasp what Web 2.0 is by comparing how it is different from Web 1.0.

Web 1.0 was about reading the internet, while
Web 2.0 is about writing in the internet.

Web 1.0 involved downloading, while
Web 2.0 involves uploading and downloading.

Web 1.0 was about companies, while
Web 2.0 is about "the people".

Web 1.0 was about passive instruction, while
Web 2.0 is about discussion.

Web 1.0 was about static web pages, while
Web 2.0 is about blogs.

On the Association of American Medical Colleges (AAMC) website, there is a great review of Web 2.0 and the idea of a "Personal Learning Environment". Go to AAMC article.

Figure from the AAMC website article

Free podcast resource for EM educators

Many podcast series are geared towards the teaching of EM literature, concepts, and pitfalls. Rarely do they focus on faculty development of the clinician-educator. One now exists by Dr. Rob Rogers and Dr. Amal Mattu (both Univ of Maryland), under the umbrella of EM-RAP by Dr. Mel Herbert (USC).

It's called "EMRAP: Educator's Edition" and it's free.
www.emrapee.com

Check it out. I especially learned a lot from the second episode on "How to Give a Great Talk" with star speakers in our field -- Dr. Joe Lex, Dr. Greg Henry, and Dr. Mel Herbert. One pitfall that they discuss is that speakers tend to cram too much information in their lecture. Instead focus on a few key points, emphasized repeatedly through examples and literature. Repetition is important. Wish I had known about this when became a faculty member.

Organizing your PDF life: Papers

How do you organize all the PDF files on your computer? For years I've been frustrated with my manual labeling system on my Mac laptop. I have scientific articles all over the place on my desktop and can't find any of them when I want to. It's like looking for that one missing sock that eloped. Frustrating.

Then one day my Chair, Dr. Mike Callaham, told me about this great software called Papers (link). I don't have any affiliation with the software. It is the best $42 I've spent in a long time. Considering that I hate purchasing software (I want everything to be free and open-source), that's saying something.

The kicker is that this works only on a Mac. The software matches your PDF with Pubmed citations, allows you to make notations, is linked with Google Scholar, catalogs your PDFs, and has a search feature. For an extra $15, you can also get the iPhone version which syncs with your desktop version. An amazing platform.

In theory, I can read EM Clinics of North America review articles while sitting on the beach or sitting in boring meetings. OK, I said "in theory".

Question for you: What favorite software do you have on your computer?
Please use the comment link below.

Top 10 list: Pearls in wound closure

This is a list of pearls and pitfalls that I share with the medical students and interns to whom I teach suturing and wound closure techniques. I can't tell you how many pigs feet I have seen in my lifetime. Feel free to use and add to the list.

10. Assume that all wounds have a foreign body in them.
9. Assume that no one will take out sutures or staples unless you tell them to. Don't forget discharge instructions for suture or staple removal. Scalp staples in for 6 months = bad.
8. Irrigation occurs AFTER local anesthesia (not before). Ouch.
7. Don’t forget to irrigate! “The key to pollution is dilution.”
6. Don’t forget to perform a neurologic exam before instilling anesthetic.
5. Assume that all tissue adhesives are purposely designed to run directly towards areas that you don’t want, such as the eye.
4. Don’t forget to clean up all sharps and used equipment when done.
3. When finished, take an extra few seconds to apply a nice bandage.
2. Assume that all wounds will get cellulitis, especially of the hands and feet. Be sure to warn patients of what to look for.
1. Assume all patients will "syncopize" during the procedure. Usually it's a 300-lb person who will fall directly on little ol' you while you are anesthetizing or irrigating a wound. Seat patients in a gurney with their legs up.

I also refer the students over to my videos on wound closure techniques at:
http://www.emresidency.ucsf.edu/Resource/Education.html

Sneak peek: ENT "Tricks of the Trade"

I just submitted my quarterly column installment on Tricks of the Trade in ACEP News on ENT dilemmas. Kids (and adults) get the most bizarre things in their ears and noses. I’ve seen a cockroach and Q-tips in the ear, and peas and pebbles in the nose. What have you seen, and what are your tricks for getting these things out?

A tool that is sometimes helpful for foreign body extraction is an ENT right-angle Day hook. In a resource limited ED, however, one can be fashioned using a paperclip, hemostat, and pen. Bend the paperclip tip to the shape of right-angle hook using a hemostat and secure onto a pen end, which serves as a handle. This hook can be gently inserted into the nose or ear and slid past the partially obstructing foreign body. By first rotating the instrument 90 degrees, pull the object out using the hook.

A general tip for removing foreign bodies is to use adequate hands-free lighting. Standard room lighting is inadequate. A directed beam of light can be attained using an ENT headgear light or alternatively a camping LED headlamp. You look a little geeky, but it's worth it.

Article review: Time management tips

I wish I had more time in the day.

I was just browsing through the February 2009 Academic EM journal and came upon a commentary "Tuesdays to write... A guide to time management in academic emergency medicine" by Dr. Steven Lowenstein (Univ of Colorado at Denver). In the article, he outlines six time management tips to all of us trying to balance the pressures of our life with clinical care, research, teaching, and administrative duties, amidst an avalanche of hourly emails. I hate to admit it, but I am guilty of falling into most of the traps that he mentions. Here's my summary.

1. Reserve Tuesdays to write.
This technique involves planning out the week, such that you have several hours each week for a "microsabbatical" when you aren't checking emails, attending meetings, and answering calls. This time is reserved for "uni-tasking" (I just made up this word) and working on academic projects. Writing rarely happens spontaneously. You need to schedule time for it.

2. Make your absence felt.
As a corollary to #1, when writing or working on a project, shut off all potential distractors such as email, phone, etc. Imagine doing work on a plane (except with less cramped seating!).

3. Control your email.
Although I personally find it oddly satisfying, apparently answering all your emails for the day or clearing your inbox actually isn't a good use of your time. It's time that could have been spent working on projects. Instead try checking your email twice daily, for instance.

4. Get to no.
I'm notoriously poor at this skill, despite being keenly aware of my deficiency. I like the quote the author found by theologist Barbara Brown Taylor: "Learning to say no is how we clear space [in our professional lives] for a few fully planted yes's to grow."

5. Know when to fold 'em
I'll never be a good poker player, since I'm stubborn and don't know when to fold 'em. I'm slowly learning though. Must learn when to walk away from a project or task because of unachievable goals or expectations. Another great quote by WC Fields: "If at first you don't succeed, try, try again. But then quit. There's no point in being a damn fool about it."

6. Add deadlines to your dreams
Self explanatory.

One time management tip that I learned several years ago, for those of us taken hostage by our emails, is to send yourself email reminders. Seeing emails from myself appear in my inbox ("write first paragraph to crowding research paper" or "speak with statistician to clarify results") helps brings my academic projects to the top of my mental "to do" pile again. Emailing yourself is ok, but I'd worry if you started talking to yourself.

Question for you: Do you have time management tips?

Work in progress: "Choose your own adventure" education for medical students

Remember as a kid when you loved reading those "choose your own adventure" books? I think that this, in the form of microsimulation, is the wave of the future in medical education -- more so than high fidelity macro-simulation (which I know is a controversial statement). Microsimulation is just a form of simulation, which is conducted on a personal computer without a physical component such as a mannequin.

I'm working on such a microsimulation model for CDEM, called Digital Cases in Emergency Medicine (DIEM). Students can manage undifferentiated patients in a more realistic fashion. The cases are timed, and the students need to complete the ED medical chart on the patient case at the end. Ideally these DIEM cases will allow students to have "managed" a spectrum of medical and traumatic conditions before graduating medical school, which is a U.S. medical school requirement according to the Liaison Committee for Medical Education (LCME).

I've been spending the last year slowly learning Adobe Flash to build a demo case. It's an incredibly powerful and versatile software. Now if only I knew how to harnass all of its features. It's a work in progress, but you are welcome to get a sneak peak into the VERY EARLY stages at:
http://www.cdemcurriculum.org/diem/DIEMcase1v2.html

Select the "Chest Pain" case. Please feel free to comment and make suggestions. If I do this right, DIEM cases will be a novel learning tool for all U.S. EM clerkships, similar to how CLIPP cases serve as great resources for U.S. pediatric clerkships.

Fortunately, my friend Dave has generously volunteered to help me get past some of the technical hurdles which have stalled my momentum. I caught him as he's on a work hiatus, because he's transitioning jobs from Yahoo to Facebook. I'm lucky to have friends smarter than me.

Behind the scenes: EM Cast with Dr. Mattu

Last month I had the privilege of doing a short podcast talk on Pitfalls on Low Back Pain. Dr. Amal Mattu (Univ of Maryland) hosts these monthly EM Casts on Emedhome.com (where DOES he find the time?!) and was in town lecturing at our department's High Risk EM Conference. He tours the country giving lectures and, while at the conferences, he interviews lecturers about what they just spoke about. I wish I had thought of this idea. Pure genius.

If you know Amal, you know that he has this unique ability to put you at ease and make you feel like he's your best friend just having a chat over coffee. So, when we did our podcast, it was pretty casual and we were joking around. Little did I know that the rest of his podcasts have a more serious tone. Thanks a lot, Amal.

The podcast just got published online this week. Fortunately by the power of editing, I sounded borderline competent. For instance, I started by talking about the basics. There are 4 "red flags" of back pain: fractures, cauda equina syndrome, spinal infection, and vertebral malignancies. For the life of me, I couldn't remember "vertebral malignancies" during the recording session. We spent a good 5 minutes just laughing at the fact that I couldn't remember it. It was a TIA moment, especially considering I had just given a one-hour lecture on this just about 10 minutes ago. I started and restarted several times with lots of flustered stuttering, before I just decided that I would change the national guidelines such that there are now THREE red flags of back pain, according to me. Fortunately that got edited out. You'll notice in the podcast snippet below that there's this awkward, pregnant pause after listing the first 3 conditions and then "malignancies" gets edited in. Nice, Amal. Nice.

Everyone needs an advisor / mentor

Do you remember in college or medical school when you had to identify an advisor or mentor? It's hard, but finding a great advisor/mentor is the key to success.

Throughout residency and at the General, I've been lucky to have several. I came upon them by being at the right place at the right time. I randomly joined a medical education research project with Dr. Wendy Coates (Harbor-UCLA), and she got me immediately involved with SAEM. Little did I know that she's such a powerhouse and recognized name in EM education. She still has nuggets of wisdom to share with me to this day.

At the General, I've been lucky to have Dr. Ron Dieckmann, guru of pediatric EM, as my mentor. I've learned from him --

* You have to think big
* Surround yourself with great people, because you can't help but be successful around them.

His little office project, now called PEMSoft, quickly became an internationally-known decision support software for pediatric care. Now that he's retiring in July, it will be hard to keep up with all his big plans for our nonprofit organization, KidsCareEverywhere. His plan in a nutshell - world domination. See the logo? It's crazy- I came up with the preliminary idea on the back of a grocery receipt while cooking dinner one night.

In the hopes of improving advising for medical students interested in EM as a career choice, I have been working on behalf of CDEM (Clerkship Directors in EM) to revamp the now-defunct Virtual Advisors Program. I fully confess that I have been holding it hostage for a year, since I never quite built enough momentum to complete the project. It will be called E-Advisors. And yes, I know that it sounds a little too much like an online dating service.

I spoke today with an awesome EM clerkship director at Maine Medical Center, Dr. Megan Fix, who will be taking over and running with this project. I'm fully confident that with all her enthusiasm, we can resurrect the E-Advisor program from the dead. This will start by focusing on advising students from 10 pilot medical schools, which currently do not have a home EM residency program. There are interested medical students in need of advisors and CDEM faculty willing to advise. We just have to build that bridge.

Question to You: What's the best piece of advice that you've gotten from your mentor?

It's WAY too crowded in the Emergency Dept

It is a sad commentary on ED's across the country when extremely crowded clinical conditions are being seen as the norm. It's been shown that crowding negatively impacts patient satisfaction, delays the administration of pain medicines, and increases patient mortality.

I'm working on a study that I conducted with my research associate Sandi, assessing whether a crowded clinical environment impacts teaching. This came up after writing a paper with Dr. Philip Shayne (Emory) on the sad state of literature looking at this question. We have many students, interns, and residents at the General, and anecdotally faculty find that there is less teaching when there are just too many clinical "fires" to put out simultaneously.

In our study, Sandi furtively recorded the clinical activities of 19 attendings over the past few months. I've seen her creatively listen from behind curtains, hide around corners but still within earshot, and generally look busy with other duties. I think she was a spy in a former life... I just sent the data to the statisticians. We'll see.

Work in progress: Tricks of the Trade column

I write a column for ACEP News on "Tricks of the Trade". This next installment will be on ENT pearls, co-authored with Dr. Deb Colina at Michigan State's EM residency program, who once was my UCSF medical student advisee. It is amazing what kids can put in their ears and nose, and even more amazing the amount of creativity that EM physicians have to get them out. I am working on getting less-blurry, higher resolution images to submit to the editor's office in the next few days. If you don't have a digital SLR camera already, I highly recommend getting one for fun and work.

Joining the blogging world

I am joining the Web 2.0 world of social networking and am inspired by all the medical blog sites out there. As an Emergency Medicine faculty member at San Francisco General Hospital and Trauma Center, the county affiliate hospital to UCSF, I have gravitated towards a niche in medical education and particularly how it intersects with new technologies.