A Lexicon for the Workplace

We have many Research Associate volunteers who staff the SF General Emergency Department collecting research data. They are often ask "what did you mean when you said..." or "what does that mean on the patient census whiteboard". When I answer their questions, they often chuckle. This then made me realize that we routinely use terms and phrases that aren't part of the usual medical vocabulary and are unique to the SF General ED.

• HACito: For acutely agitated patients (often under the influence of one or more intoxicants), we commonly use Haldol, Ativan, and Cogentin in a single syringe to inject intramuscularly. This is commonly referred to as HAC. For smaller patients or those who just need only slight chemical restraint, we use a smaller dose of HAC, or a "mini-HAC" or "HACito" .
  
• Syncopize: Many medical nouns are converted into new verbs when we speak to each other. "Syncopize" describes one who has had an episode of syncope. "Hematemesize" describes one who has vomited blood.
  
• MTF: Many of our patients present because they are under the influence of alcohol, heroin, methadone, cocaine, amphetamines, or a combination of them all. After several hours, these patients wake up and are discharged assuming nothing else is wrong with them. For these patients, we write "MTF" on the whiteboard next to their name, meaning that we are waiting for them to "metabolize to freedom".
  
• The eagle has landed: Some mornings, often a nurse or institutional police officer buys several dozen donuts for the ED staff. Instead of sending out an overhead annoucement that donuts are in the break room, the code words are "the eagle has landed".
  
• Trauma Alpha: All of our severely-injured trauma patients fall under code names, chronologically arranged in alphabetical order. These pre-printed medical charts have pre-registered medical record numbers to allow us to immediately start ordering labs and other diagnostic tests. There's Trauma Alpha, Trauma Beta, Trauma Charlie, etc. You know it was a bad trauma day when the ED cycles the entire alphabet in a 12-hour shift.
  
• Med Pack Whale: Similarly for our acutely ill non-trauma patients who need tests started immediately, we have pre-registered, pre-printed medical chart packets for them. These are also arranged in alphabetical order, except we use animal names. I always feel bad that we have a Medical Packet Whale, especially if the patient happens to be a little overweight. Some of my favorite are Med Pack Giraffe and Med Pack Yak, FYI, I have really bad luck with Med Pack Kangaroo. For me, it is an independent predictor for intubation. My intubation rate is about 80% on them!
  
• Platinum CT scan: Are you getting pan-scans for more and more of your trauma patients, despite the recent irradiation risk literature? I've started calling the head, cervical spine, chest, and abdomen/pelvis CT set as the Platinum scan. If we don't need the chest CT, I call it the Gold scan.
  
• IP: The Institutional Police are a omnipresent staple in our ED. Stationed only the ED, they are extremely protective of our ED staff whenever patients become unruly, potentially dangerous to the staff, or refuse to be discharged from the ED. Until recently, we had an IP officer named Frank who was amazingly adept at convincing patients to calm down and be respectful. I suppose having a gun on your belt helps at being convincing. You would often hear an overhead page calling for "Uncle Frank". I describe our IP officers as "motivational speakers".
  

Question: What unique phrases/terms do you have at your ED?


On an aside, I wanted to let you all know of a conference in Cape Town, South Africa on November 23-26, 2009 called "Emergency Medicine in the Developing World". http://www.emssa2009.co.za. It looks like an amazing conference with some all-star speakers in the U.S. including Dr. Amal Mattu, Dr. Joe Lex, and Dr. Rob Rogers. Where DO these speakers find time to attend all these conferences!? I barely have time to travel to the grocery store and back.

Hot off the press: Free podcasts of key EM lectures

Audio podcasts files are still a popular way for medical students, residents, and faculty to keep up to date about Emergency Medicine topics. They are much more portable than video-based lectures since you can be doing other things while listening to the podcasts. Many great audio lectures are available with paid subscription to such services as EM-RAP and Emedhome.com, among many others.

However, my good friend Joe has amassed hundreds of open-source podcasts which are available for free download. Dr. Joe Lex is the legendary from Temple University and THE MAN behind many of the educational events for AAEM and the previous Mediterranean EM Congresses (Valencia, Nice, Sitges...). He's doing this to help out the global EM community. You can listen to these in your car, on the shuttle, or while on a nice walk around your neighborhood.

Click on this link to download the Excel list of files. The files are housed in YouSendIt.com.

Speakers range from budding to established speakers in EM. Lectures were compiled from many events, including Temple Grand Rounds, the recent Giant Steps CME conference, the 2008 AAEM Scientific Assembly, 2008 Cancun EM Conference, 2009 Carribean EM Congress, and 2009 Manchester Critical Care.

I totally forgot that I had signed my release for these audio recordings, and I'm happy to see my Vascular Tricks and Tricks of the Trade talks appear. I know it's odd, but I've never listened to my own talks. Too self-conscious. If you listen to them, don't tell me!

Tricks of the Trade sneak peak: Teaching procedures

Teaching procedural skills in medical school is increasing falling on the shoulders of emergency physicians. Two common problems that arise are the equipment expenses and simulation of realism. Working with my colleague Dr. Jeff Tabas, we came up some creative ideas around the teaching of (1) the Seldinger technique for central line placement and (2) saphenous vein cutdown.

Seldinger technique
The concept of "keeping the wire in the vein" is often a difficult concept to explain and visualize when walking through the steps. One can demonstrate and practice the procedure by using a transparent foley catheter tubing (ideally an unused one!), which substitutes as the vein. The transparent tubing allows the learner to view the wire, resting in the vein at all times.

Saphenous vein cutdown

A saphenous vein cutdown kit can be quite pricey. Alternatively, all you really need to gather are:

• Scalpel
• 3-0 silk ties without needles
• 18-gauge angiocatheter
• Dental floss pick

The 90-degree pointed end of the dental floss pick functions exactly as a saphenous vein elevator/hook, as seen in this medical student volunteer. (Just kidding, this was at a cadaver procedural lab.) I bought a pack of 50 dental floss picks for $5.

Sneak Peak: CDEM e-Advisor Program almost ready

The Clerkship Directors in Emergency Medicine (CDEM) group is about ready to officially launch the e-Advisor Program!

The e-Advisor program will be replacing the successful but unfortunately retired SAEM Virtual Advisor Program. The first phase of the program is to target medical schools, which do not have a home Emergency Medicine (EM) residency program. Students from such medical schools are traditionally thought to be at a slight disadvantage compared to students from other schools, because they do not have easy access to EM faculty who are intimately involved with the residency application, screening, interview, and rank-listing processes.


Each school will have a team of 2-5 geographically diverse CDEM faculty advisors who will be available to advise students potentially interested in EM. Students can think of them as their own personal "A-Team" (remember that great TV series?). They can help students figure out such questions as:

• How many residency programs should I apply for?
• How competitive am I, given my CV and application?
• Who should I get letters of recommendations from and what's a SLOR?
• How should I plan my 4th year?
• What is interview season like?
  

Here's a sneak peak at the first 10 medical schools, which were selected for the e-Advisor Program. The Emergency Medicine Interest Groups (EMIGs) from these schools have all expressed interest in being part of the pilot group.

• Baylor College of Medicine (Houston, TX)
  
• Dartmouth School of Medicine (Hanover, NH)
  
• Meharry Medical College (Nashville, TN)
  
• Rush Medical College (Chicago, IL)
• Sanford School of Medicine of Univ of South Dakota (Vermillion, SD)
  
• Touro University College of Osteopathic Medicine (New York, NY)
• Tufts University School of Medicine (Boston, MA)
• University of Miami School of Medicine (Miami, FL)
  
• University of Missouri School of Medicine (Columbia, MO)
• University of Vermont College of Medicine (Burlington, VT)
  

Phase 2 will provide e-Advisors to another 10 medical schools. This time, schools with or without home EM residency programs, will be eligible. Medical schools will be chosen based on those who request the CDEM e-Advisor service. For those schools with residency EM programs, out-of-state e-Advisors will be provided.

Kudos to Dr. Megan Fix (Maine Medical Center), who has been leading the charge to make the CDEM e-Advisor Program a reality.

Questions: Would you like for us to consider your medical school as part of Phase 2 of the e-Advisor program? If so, email me at Michelle.Lin@emergency.ucsf.edu.

Article review: The ABCs of manuscript writing

I came across a practical and insightful review article written by Dr. Mark Langdorf (editor-in-chief of West JEM) and Dr. Steve Hayden (editor-in-chief of Journal of EM) outlining how to write a manuscript for publication. This is a crucial skill because paper publications are the standard unit of currency in academics, which then translates into promotions and academic credibility. Although this article primarily targets novice manuscript writers, it's always nice to get the perspectives from Mark and Steve, editors-in chief of two major EM journals.

Take home points - OVERALL:

• Be sure your manuscript fits the "mission" of the journal. This can be found in the journal's "Aims and Scope" section.
• Follow the journal's instructions very carefully for manuscript formatting and submission.
• Think from the perspective of the journal editor. Extra pages cost money. Thus, every word and every sentence should have a purpose. Brevity is valued. The authors suggested that most manuscripts can be trimmed 30% without compromising content.
  
• Use active verbs rather than a passive ones. These sentences are shorter and more direct.
• Each paragraph should have 3-6 sentences. More or fewer sentences disrupt readability.
• Check out the appendix at the end. It provides a nice summary checklist when you are writing your manuscript.

Take home points - MANUSCRIPT SECTIONS:

• Introduction: This should be not be a comprehensive literature review. It is typically only 4 paragraphs long and commonly ends with "we propose that" or "our objective was".
• Methods: Have a statistician or research mentor review this section for clarity, accuracy, and completeness.
• Results:
  
1. For complex or multiple results, consider using a graph or table. This improves clarity and readability. The associated text does not need to repeat the displayed graph/table. A synopsis is sufficient.
2. If using graphs or tables, label key findings well because they may be removed as stand-alone figures.
• Discussion: Highlight your primary finding first. In this section, be sure to address how your study might change current practice.
• Conclusion: Beware of overstating your conclusion. The conclusion should only comment on the research question that you studied.
• Limitations: In 1-2 paragraphs acknowledge the major study flaws. The most common limitations include: small sample size, patients lost to follow-up, bias, retrospective design, non-blinded methodology, and lack of generalizability.
• References: Conform with the journal's formatting for citations. Be sure to search the literature one more time before manuscript submission.
  

Because West JEM is an open-access journal, you can download this article for free!

Reference:
Langdorf MI, Hayden SR. Turning your abstract into a paper: academic writing made simpler. West J Emerg Med. 2009 May;10(2):120-3.

Three phases of educational technology in the classroom

I recently encountered a thought-provoking video about how technology is transforming education in the classroom setting. We are slowly experiencing a culture shift in how learners are learning. It follows that this should affect how teachers should be teaching. Briefly, the author lays out the progression of educational technology in 3 phases.


Phase 1: Using Technology to Present Dynamic Lessons

• Prime example: Powerpoint presentations
• Generally passive learning
• Learners are consumers of information
  

Phase 2 – Using Technology to Access Information

• Learners search online for answers to questions
• More active learning
  

Phase 3 – Using Technology to Produce and Share Products

• Learners move towards becoming producers of information and engage a larger audience
• Creators of information
• Classic example of Web 2.0 learning
  

Looking at my own experiences when I was a medical student and EM resident, my learning environment was clearly in Phase I. Lots of powerpoint presentations in sleepy, dimly-lit rooms with the lecturer being the only voice in the room. Currently, in our new EM residency program, I'm starting to see evidence of Phase II. Journal club sessions sometimes utilize real-time online searches to find answers to methodology questions.

After watching the below inspirational and thought-provoking video, I'm committed to incorporating some Phase II/Phase III approaches to my "lectures" in the future. The first quote really hits home:

A teacher that can be replaced by technology deserves to be."
- David Thornburg

I have a lecture this coming Thursday on "Troubleshooting the Vascular Access Patient". I'm re-tooling the talk to make it a more interactive session. I'll let you know how it goes. There's less control (from a speaker's perspective) when venturing outside of the Phase I format, which makes me a little uncomfortable, and so I'm crossing my fingers that it will turn out ok... I've got a few things up my sleeve though.

Question: In what Phase is your teaching or learning experience?

iPhone Shortcuts: Secret keyboard tricks

The iPhone has revolutionized how I manage my work day. If you check and send emails as much as I do on the iPhone, any shortcut potentially saves me hours of time.

When I found out these keyboard shortcuts, I just had to share with you. I'm not sure why this isn't publicized more widely!

I made a short video of the shortcuts. It's easier to understand once you see the shortcuts in action. You may need to select the full-screen mode to see better (button under the "You" of YouTube logo).

Before

• To type a sentence such as -- They've thought of it all! -- you'd need to toggle back and forth between the alpha character keyboard and the numbers/symbols keyboard using the .?123 button. The apostrophe and exclamation mark are on the numbers/symbols keyboard.

Now

• Apostrophes are automatically inserted for you in common contractions. Just type the word without the apostrophe and the iPhone automatically will insert the apostrophe. For words which may be words without the apostrophe (eg. we're/were, it's/its), just type the last letter twice and the word will be contracted. So type weree for the word we're.
  
• To just access one number or symbol while remaining on the alpha character keyboard, select the .?123 button. Next, WITHOUT LIFTING YOUR FINGER, drag your finger to the character that you want. Then let go. Notice that this will print on the screen, and your keyboard returns automatically to the alpha characters.

Before

• In the Safari browser, there is a .com button when typing an URL address. However, what about .edu or .org? Before, I'd type the letters in manually.

Now

• If you keep your finger on the .com button, more options will appear. Similar to shortcut above, you can select the suffix you want by dragging your finger over to it. Upon releasing the button, the suffix prints on the screen.
  

Trick of the Trade: The Digi-Speculum

Frequently patients present to the Emergency Department for lacerations, partial amputations, and abscesses of the fingers. After repairing the wound or injury, however, a bandage can be a bit unwieldy to apply and difficult to secure. To me, an ugly bandage just seems to detract from all of the diligent work that you just put into a plastic surgeon-quality wound repair.

What's my solution?
A soft, cotton tubular gauze is widely available commercially. It often comes with a commercially available gauze applicator instrument. However, if your ED is like mine at SF General, anything small, portable, and NOT bolted to something heavy and unappealing will disappear before you can say "abracadabra ". Thus the tubular gauze applicator is often missing.

As an alternative, our creative nurse practitioner Tina King, devised what I like to call the DIGI-SPECULUM. I use a plastic pelvic speculum, which is always available in the ED. After loading the tubular gauze on the speculum, 3-5 layers of the gauze can be applied. Be sure to twist the gauze a few revolutions just beyond the tip of the finger when applying layers to help secure the gauze in place. Tie the bandage in place at the wrist, after cutting the remaining tubular gauze longitudinally to generate 2 tails.

This photo was from my shift last night of a patient with a small thumb avulsion which kept oozing blood because of the vascularity of the nail bed. The bandage helped apply strong direct pressure over the wound to achieve hemostasis. He chuckled at our Digi-Spec.

Warning: Be careful of applying this circumferential bandage on patients with an underlying sensory neuropathy of the digit. There are very rare case reports of digital necrosis from such bandaging in patients who can't tell you that there's more pain from tissue ischemia.

Pearl: Be sure to twist the gauze only when beyond the finger tip rather than at an area overlying the finger (to avoid a tourniquet effect). Also, be sure that the dressing is not too tight before discharging the patient.

Work in Progress: Visual Aid Project

Practicing at an academic ED, such as in San Francisco General, I find that I am constantly surrounded by medical students, interns, and residents. Most are working on shift with me, but occasionally I have medical students shadowing me to learn more about the Emergency Medicine specialty.

Have you ever had a person shadow you (excluding your annoying little brother when you were a kid)? It's actually a little stressful for me, because I want the shift to be a positive learning experience for them. Inevitably, it doesn't take long before I get immersed in mundane troubleshooting activities (eg. calling to transfer a patient to another facility, coordinating the CT scan priority list, paging the inpatient team for admitting orders).

So starting about a year ago, I created the Visual Aid Project (VAP). The goal of this project is to collect HIPAA-compliant digital photos of interesting clinical images in the Emergency Department. We have so many fascinating findings and iconic images of "life in the ER" that I've always regretted not capturing these on camera. Since its inception, I've used VAP images for a Clinical Images publication in Annals of EM, various lectures, and now this blog!

What does this have to do with the shadowing student?
I have the student carry my digital SLR camera and a stack of hospital photo consent forms. He/she takes clinical photos, paying special attention to avoid photos of identifying features such as the patient's face to maintain anonymity. I thus far have over 1000 photos, each paired with a photo of the signed consent form. Since the creation of the VAP database, I've had volunteers from our ED Research Associate pool, who are closet photographers, also join me on shift to capture amazing photos for the project.

I regret not having a VAP photographer on shift with me these past 2 days, because I've seen:

• Hyphema and subsequent glaucoma from an assault
• Arterial injury to the peroneal artery by shattered glass after falling through a window
• Really impressive pharyngeal exudates from strep throat
• Early Fournier's gangrene
• Ear abscess
• ST elevation MI on EKG in a 38 y/o male
• A myriad of double- and triple-parked ambulances in front of the ED

Below is a glimpse into the SF General ED through the Visual Aid Project.


Yes, sadly despite President Obama's push for electronic medical records by 2011, we are still using paper charts. I feel like I spend half my shift always looking for charts! Anyone have a few million dollars to donate to our ED?





Ketamine procedural sedation was crucial to precisely repair a lip laceration.






As the only level-one trauma center in San Francisco, we work closely with the paramedics and EMS system.






Syphilis is making a comeback in San Francisco. Palmar rash seen in a HIV patient with fever and diffuse body rash.







I think I must take 5-10 people off backboards in an 8 hour shift.









Bedside ultrasounds are an invaluable tool in the ED, especially with central venous line placement, such as for this IJ line that I was doing.



The Visual Aid Project has been a successful ongoing project. The student gets to talk with patients (obtaining photo consent), observes what life is like in EM, sees many interesting procedures and findings, and contributes images to my growing VAP database. It's a win-win situation.

Article review: Standardizing the EM clerkship patient encounter experience

As a medical student, do you remember your EM clerkship experience and whether you saw a wide variety of patient chief complaints? Did your fellow medical student on the EM clerkship rotation, who was going into Orthopedics, seem to only see patients with orthopedic complaints?


In a study in Academic EM in 2008 at Harbor-UCLA Medical Center, medical students were provided a list of 10 chief complaints which they had to see during their 4-week rotation. These chief complaints were:

1. Abdominal pain
2. Acute coronary syndrome
3. Asthma
4. Diabetic ketoacidosis / hyperglycemia
5. Headache
6. Laceration
7. Orthopedic injury
8. Pediatric fever
9. Traumatic injury
10. Vaginal bleeding

When I last spoke with Dr. Wendy Coates (one of the authors), this study arose because she found that medical students, if left on their own, will NOT see a variety of patients during the EM clerkship rotation.

This was a prospective, non-randomized, case-control study. The control group (n=18) included students who saw whichever patients they desired during the EM clerkship rotation. The test group (n=24) included students who were assigned to see each of the 10 listed chief complaints during rotation.

Results: Using a difference in means analysis, the test group students showed greater exam score improvement (post-test score minus pre-test score), compared to the control students. What was interesting was this exam tested a broad range of topics including and beyond the 10 assigned chief complaints.


Some ideas
After reading this article, I find myself thinking about whether a similar approach might be applied in other settings.

1. I think this would be terrific idea for interns (PGY-1 residents) on the EM rotation. Many interns from a variety of departments rotate through the Emergency Department to gain a broad experience in managing acute medical conditions. Although I find that most interns are open to seeing a variety of chief complaints, several naturally gravitate towards only seeing patients with complaints which are directly relevant to their specialty. This checklist of chief complaints would encourage interns to gain a more balanced and broad EM knowledge base.
2. Another idea -- there could be a completely different checklist of chief complaints for students who are rotating on their second EM rotation. These chief complaints could include more advanced topics such as: eye complaint, acute back pain, drug of abuse, and seizure/stroke.

Do you have any ideas or thoughts?

Reference:
Lampe CJ, Coates WC, Gill AM. Emergency medicine subinternship: does a standard clinical experience improve performance outcomes? Acad Emerg Med. 2008 Jan;15(1):82-5.

Hot off the press: Two journals join Medline

If a journal gets accepted it into the Medline database, it is viewed with significantly more legitimacy. It follows then that your academic CV is better regarded if your publications appear in journals which are listed on Medline. Plus, it's just fun to see your name listed in Pubmed when you search yourself! Hmm, that sounded more egotistical than I intended, especially since I don't have that many publications on Medline...

I wanted to let you know of 2 journals which have just joined the Medline "family". They are worth a look-see. Congrats to both journals for pulling off this Herculean task.


1. Western Journal of Emergency Medicine (West JEM)
After years of working towards getting this journal into Medline, it has finally come true. Led by the efforts of Dr. Mark Langdorf (UC Irvine), Dr. Shahram Lotfipour (UC Irvine), and Dr. Sean Henderson (Univ of Southern California), this journal is worth considering for your Emergency Medicine publication. Shahram also tells me that West JEM is also going to be included in the EM Journal Watch review series, which summarizes key articles from the major EM journals.

2. Medical Education Online
This journal is uniquely an open source online journal dedicated primarily to medical education since 1996. I'm pleased to see it join the family of Medline journals.

Cool web trick: Schedule a meeting using Doodle

Have you ever tried to coordinate a dinner amongst friends and realize that it takes tons of emails to agree on the most available date and time? Don't even get me started about choosing the restaurant...

Similarly up until a year ago, I had found that I spent a good deal of email time just trying to set up meetings for work. Life in academics inevitably involves in-person and conference call meetings with people who have extremely busy schedules.

I've always thought that there's GOT to be a technological solution to make this process easier and save you time. And walla, there is.


Doodle.com, a Swiss-based company, is a FREE and very user-friendly website, which allows users to input their availability for a particular meeting. The website then displays the best dates/times when people are free to meet.

In brief, it is a scheduling wizard (my shout-out to the great Harry Potter movie debut this week).

As a meeting coordinator, all you have to do is to name the "event" and select a list of dates and times. Doodle does the rest. It generates a unique link which you can email to the meeting attendees. These attendees then click the times when they are available. With each user entry, the software collates all the information, such as below (click image to see larger size):

Another really nice feature is that you can set the time zone. This is especially helpful for conference calls across time zones.

I'm always on the losing end of conference calls, since I'm on the west coast. I have frequent conference calls with CDEM Executive Committee members, most of whom are on the east coast. The early morning calls are a variant of torture, for those of us who are night owls.

Sneak Peak "Trick of the Trade": IO line for failed IV access

Nothing frustrates me more than not being able to obtain intravenous access in hemodynamically unstable patients, especially because I give a talk on "Troubleshooting the Difficult Vascular Access Patient."


What would you do in this trauma case?

* 30 y/o man with multiple gun shot wounds in his right chest and arm. In PEA arrest. No IV access obtainable peripherally or centrally. IV access slowly being established via a saphenous cutdown. You know he's bleeding internally and needs aggressive fluid resuscitation, blood transfusions, and operative repair.


Adult intraosseous needles are coming more into favor in the United States, although they have been part of standard practice in the military and Europe. Various commercial devices exist. The one we have at SF General is the EZ IO Needle. (I have no financial ties with the company.) Needle placement is surprisingly easy and takes less than 10 seconds, especially if you channel your inner Home Depot self in using the power drill.

In the video below, 3 brave (a.k.a. crazy) volunteers get an IO drilled into their proximal tibia. Apparently, the insertion is only mildly painful and the infusion of fluids is actually the more painful part of the procedure. You might consider priming the IV tubing with 1% lidocaine to minimize pain in awake patients.

Faculty spotlight: Dr. David Wald

I've had the pleasure of knowing Dr. Dave Wald for several years now, working on projects and committees in Clerkship Directors in Emergency Medicine (CDEM) and SAEM. He is a true advocate for undergraduate medical education, and it is no surprise that he is the natural choice to be this year's CDEM Chair. As much as those us on the Executive Committee of CDEM give him a hard time for his extremely long emails and gullibility (be sure to ask him about a recent $800 dinner bill we left him with), we can't deny that Dave is a true outspoken leader in medical student education.

David A. Wald, DO
Associate Professor of Emergency Medicine
Director of Undergraduate Medical Education
Associate Course Director - Doctoring Course
Temple University School of Medicine (Philadelphia, PA)

EM residency training: Albert Einstein

1. Dave, what’s your academic niche and how did you decide on it?

Currently, my interests lie primarily in undergraduate medical education. When I started at Temple University Hospital I became actively involved in our departments EM residency training program. At one time or another, I was involved in all aspects of residency administration. Although I still play a role in resident teaching, over the years I have transitioned the majority of my non-clinical time and emphasis to undergraduate medical education serving as Director of Undergraduate Medical Education in our department, EM Clerkship Director, and Associate Course Director, Doctoring Course for Temple University School of Medicine.


2. Wow, how did you manage to carve out this career path? At times just being in the right place and getting involved can make a huge difference. About 6 years ago, I volunteered to take on the role of Chair of the SAEM Medical Student Educators Interest Group. This was a great opportunity to perform research with faculty at multiple institutions and start to develop a name for myself outside of my home institution. The relationships that I developed ultimately led to friendships and other opportunities. In the past 2.5 years I have been lucky to work with some of the best educators in our specialty and have from the ground up have been able to assist in the development of the Academy of Clerkship Directors in Emergency Medicine. It is amazing what can be accomplished with even just a few hardworking and motivated individuals.

3. Who were your mentors?
Mentors to me were Douglas McGee, DO (Prior EM Residency Director at Albert Einstein Medical Center) and Kip Wenger, DO, years back served as EM clerkship director at Einstein Medical Center.

4. What’s a project that you are working on now?
Presently, I am working on a number of projects. At my home institution, I am working to further incorporate simulation into the undergraduate curriculum. This is primarily focused on initiatives in the MS I and MS II years. For the past 2 years, I have worked with a small group of basic scientists to develop and refine a set of problem based exercises using high fidelity simulators. We continue to refine these exercises and to date have developed 6 exercises; diabetic ketoacidosis, ventricular tachycardia, complete heart block, asthma exacerbation, opioid overdose, and hemorrhagic shock.


5. What words of wisdom can you share with those interested in or just starting out in academics?
For those of you contemplating a career in academic EM my advice is to get involved early. Often just being enthusiastic, hardworking, and showing interest goes a long way. Find a mentor, most often this can be someone who has similar interests to help guide you along the path. Emergency medicine is perhaps the most proactive specialty for those interested in an academic career. The sky is the limit.

What procedures should med students know before graduation?

Nationally, medical students receive variable procedural training during medical school. Some get great hands-on experience with procedures and others hardly any. Recently, much of the responsibility for teaching procedures in the medical school curriculum has fallen on the shoulders of emergency physicians (for better or worse).

But a question arises: What IS the minimum required procedural competency for the average medical student, independent of specialty career choice?

The Association of American Medical Colleges (AAMC) published in their 1999 Medical School Objectives Project that the basic procedure list is:

• IV placement
• Arterial blood gas sampling
• Thoracentesis
• Lumbar puncture
• Nasogastric tube insertion
• Foley catheter placement
• Suturing

Then in 2005, the AAMC published a Clinical Skills Curriculum for medical schools, which provides an extensive laundry list of "recommended" skills in the curriculum. Because the importance of each skill isn't weighted, it's hard to tell what are the most important skills. To give you a sense of the >100 skills listed, skills included suturing, chest tube placement, pap smear, endotracheal intubation, suprapubic cystostomy, and ear wax removal. Yes, that's right - ear wax removal!

So, what do you think are the most important skills to come out with after medical school? This was the question asked in a single-site study* of EM faculty and end-of-year PGY1 residents from all specialties. Both groups were given 31 procedures to rank as "no need to know", "convenient to know", and "must know". Interestingly, there was a moderate disconnect between faculty and resident perception of what procedures should be learned during medical school.

The majority of faculty thought that 14 procedures were "must know":

• CPR
• Bag valve mask airway
• IV placement
• Phlebotomy
• ACLS resuscitation
• Arterial blood gas
• ECG interpretation
• Oral and nasal airway
• Local anesthesia
• ECG procurement
• Throat culture
• Nasogastric tube placement
• Laceration repair
• Foley placement (female) - Not sure why male foleys didn't make the list.
  

The majority of residents thought the following 11 procedures were "must know" (6 procedures in bold also appear on the faculty "must know" list):

• CPR
• Bag valve mask airway
• ACLS resuscitation
• ECG interpretation
• Local anesthesia
• Laceration repair
• Intubation
• Central line placement
• Lumbar puncture
• Abscess incision and drainage
• Arterial line placement

With both lists combined, there were 19 unique procedures. This may serve as the minimum clinical skills list for medical schools.

What's the next step?
This study should be expanded to other clinical sites where nurses, physician assistants, nurse practitioners, respiratory therapists, and other ancillary staff are more and less involved with performing procedures. This may significantly affect whether the residents rank procedures as "must know".

Anyone up for doing a multicenter survey?

* Fitch MT, Kearns S, Manthey DE. Faculty physicians and new physicians disagree about which procedures are essential to learn in medical school. Med Teach. 2009 Apr;31(4):342-7.

Work in Progress: Teaching MDs in underserved countries

One of the cool things about the field of Emergency Medicine (and especially academic EM) is that it allows physicians many opportunities to hear about, network with, and collaborate with amazing people. Projects can range from hospital-specific issues to global-health programs.

When I first met Dr. Ron Dieckmann, I realized that we just HAD to work together on something despite the fact that our areas of interests are so divergent. His expertise is in pediatric EM and mine is in educational technology. Put these together and what do you get? Our new non-profit organization, KidsCareEverywhere. We just officially were granted a 501(c) non-profit status and are launching into major projects in the near future.


What is KidsCareEverywhere?
Our goal is to transform medical technologies in pediatric care for underserved countries. We help to educate and train medical personnel in using these technologies to benefit those who most need them -- children.

What are we working on?
As a budding organization built from a grass-roots approach, we are dealing with getting off the ground. We were lucky enough to gain the pro bono services of good-hearted professionals like Lian Ng who designed our logo and website: www.kidscareeverywhere.org. I'm constantly amazed by all the passionate individuals who want to help out.

Next month (August), we will be taking our first team of very enthusiastic KCE members to "train the trainers" in Vietnam. In Hanoi, we will be hosting a conference where we will teach Vietnamese pediatricians. We will conduct a pre-post analysis of the pediatricians' practical knowledge before and after installing and learning about the PEMSoft software. This software is a medical decision-support software, generously donated by the parent company. Additionally while there, we also will upload local Vietnam hospital documents into the customizable PEMSoft software to create a "Pemsoft Vietnam" package. These documents might include hospital policies, regional bacterial resistance patterns, phone numbers, etc.

How can you help?
This week, we are looking towards finding individuals and companies who might help fund the purchase of 100 USB flash drives (1-2 GB) to load the PEMSoft software onto. These USB drives would be given to the conference participants so that they can upload copies of the software in their home hospitals and clinics, in addition to their own laptops.

If you know of anyone who might be able to help us out for a good cause, please let me know (michelle.lin@emergency.ucsf.edu).

Have a nice weekend everyone. Should be nice weather here in the Bay Area. I am typing this blog on a beautiful day before my shift starts from my office "deck". This self-photo is taken from my secret, private 2nd floor patio surrounded by 3 brick building walls, accessible only by climbing out my office window.

USC 2008 medical student symposium videos

Over the years of advising medical students interested in Emergency Medicine as a career choice, I often point them to the SAEM website where there are many practical tips and FAQs written by EM faculty across the country. Recently, I discovered that the University of Southern California EM Medical Student Symposium from 2008 was videotaped and posted online. These free video clips are a great resource for those of you advising medical students.

Go to USC's EM Core Content website.

Finding the videos
Under the Conferences menu (blue bar in the upper right), select "USC EM Medical Student Symposium". There are 10 free lectures:

Introductions (Dr. Jorge Fernandez)
ACEP and AAEM (Dr. Billy Mallon, Dr. Stu Swadron)
Career Paths in EM (Dr. Scott Votey)
Careers in EM (Dr. Mark Morocco)
Choosing a Residency (Dr. Stu Swadron)
Optimizing Your Fourth Year (Dr. Michelle Lin)
Matching Your Strengths to a Program (Dr. Dustin Smith)
Toxicology Review (Dr. Aaron Schneir)
Ultrasound Review (Dr. Rusty Oshita)
History of EM (Dr. Mel Herbert)