Paucis Verbis card: NIH Stroke Scale

Patients present with acute strokes to the Emergency Department. Time is of the essence to obtain a rapid neurologic exam, draw labs, get CT imaging, and consulting a neurologist especially if the patient presents within 3 hours of onset. To help the neurologist determine whether the patient should get thrombolytics, calculating a NIH Stroke Scale score is useful.

In this installment of the Paucis Verbis (In a Few Words) e-card series, here is the NIHSS scoresheet.

Feel free to download this card and print on a 4'' x 6'' index card.
[MS Word] [PDF]

See other Paucis Verbis cards.

Hot off the press: Free EM Practice articles

Thanks to EB Medicine, "Emergency Medicine Practice" articles from 2007 and earlier are now free! This series is a well-written and practical evidence-based review resource for EM physicians. It's a great place to start reading about bread-and-butter EM content, especially for medical students and junior residents. There haven't been too much change in the past 3 years on many of the topics.

Full list of free EM Practice articles for download.

Below are the links for the 2006-07 articles. Enjoy!

Imaging In The Adult Patient With Nontraumatic Abdominal Pain	February 2007
ED Management Of Delirium and Agitation	January 2007
Acutely Decompensated Heart Failure: Diagnostic and Therapeutic Strategies	December 2006
An Evidence Based Thoracic Imaging Curriculum for Emergency Medicine	November 2006
The Swollen Extremity: A Systematic Approach To The Evaluation Of A Common Complaint	October 2006
Diagnosis And Management Of North American Snake And Scorpion Envenomations	September 2006
Seizures and Status Epilepticus: Diagnosis and Management in the Emergency Department	August 2006
Pain Management in the Emergency Department	July 2006
The Evaluation and Management of Heat Injuries in the Emergency Department	June 2006
Acute Spinal Injuries: Assessment and Management	May 2006
Blast Injuries: Preparing For The Inevitable	April 2006
Aortic Emergencies Part II: Abdominal Aneurysms And Aortic Trauma	March 2006
Aortic Emergencies: Part I - Thoracic Dissections And Aneurysms	February 2006

Trick of the trade: Spicing up your evidence-based lecture

Before I start creating a new talk, I ask myself 3 questions:

1. Who will be in the audience?
2. How can I make my talk more worthwhile to audience members, beyond their just reading the material/handout/articles on their own?
3. Am I giving a talk before or after Dr. Amal Mattu? If so, just be resigned to being second-best.
   

Two years ago, I started giving the annual Education Journal Club talk for the CORD Academic Assembly. To spice-up these talks, I emailed the first authors of articles that I reviewed to get their insight, comments, and behind-the-scenes thoughts. Both years I was surprised by how eloquent, well thought-out, and responsive they all were. I got a flurry of emails within 24 hours! This added touch makes the articles more personal and relevant for the audience, in my opinion.

Trick of the trade:
For evidence-based talks, don't be afraid to email the publication's author(s) for more insight or clarification. You might be surprised by how approachable they are. In most cases, they are thrilled that you cared enough to ask questions.

This year, Dr. Sorabh Khandelwal (the Ohio State Univ) and I are jointly giving the CORD Education Journal Club, reviewing 2009 publications. The target audience includes clerkship directors and undergraduate medical educators. And don't worry, Amal is talking on the day AFTER us. Whew.

We are each reviewing 4 articles. I sent out emails to the first authors of my 4 articles and I already got responses back within 12 hours! Here are highlights of their responses, which I am incorporating into my slides.

Goldman E, et al. Learning in a chaotic environment. Journal of Workplace Learning. 2009; 21(7):555-74. (view earlier blog post)

• "I sent your message to the whole research team so you may be hearing from others!"
• "Post-study reflection: Encourage students and faculty to participate in research! I was very surprised how hard it was to recruit."
• Dr. Ellen Goldman (George Wash Univ), who teaches a qualitative research course in a medical fellowship program, commented about how hard it is to publish qualitative research. Disproportionate value is placed on quantitative research in medicine. There are so many misunderstandings about qualitative research, making it truly an underappreciated science. Hopefully with more excellent manuscripts like this one, things will change with time.
  

Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009 Sep 23;302(12):1309-15. (view earlier blog post)

• "It was a whirlwind study-- had the idea in August 2008, pitched it to AAMC Jan 2009, surveyed in Feb-Mar 2009 and submitted the manuscript end of April! I wish I could bottle that kind of momentum for future use."
• "My coauthors and I are big proponents of using technology in medical education."
• "I think the media interviews really focused on the negative –everyone wanted to know what the most egregious example of unprofessional posting was – while our primary focus was to say: this is something we need to be talking about, thinking about, because it’s out there and could change the face of medical professionalism as we know it."
• "We just finished a follow-up study – a focus group study of medical students and their perspectives on online professionalism. Hopefully will be presenting this data soon."
• Thanks to Dr. Katherine Chretien (Washington DC VA Med Center) for these cool behind-the-scenes comments.
  

Senecal et al. A four-year perspective of society for academic emergency medicine tests: an online testing tool for medical students. Acad Emerg Med. 2009 Dec;16 Suppl 2:S42-5.

• Dr. Emily Senecal (Mass General) will actually be at CORD and hopefully lend some in-person comments after I review her article on the SAEM Test database that is being used by most of the EM clerkships in the U.S.
• "One of the ongoing goals is to continue to integrate SAEM Tests with the online educational materials that are currently being developed by CDEM (DIEM cases, Self Study Modules, on line lectures, etc)."

Zabar et al. Can unannounced standardized patients assess professionalism and communication skills in the emergency department? Acad Emerg Med. 2009 Sep;16(9):915-8. (view earlier blog post)

• "We are currently sending unannounced standardized patients (USP) into an urban inner city community clinic [instead of the ED] and comparing the results to our resident’s OSCE scores. This is far less challenging than the ER environment but is bringing us rich data not only about our residents skills (most residents on aggregate have similar scores to the OSCE but a not insignificant group have lower scores in OSCE and than USP and another group was higher in the OSCE then the USP) but also information about the team system they work in."
  
• "This information has been fed back to the clinic and resulted in changes."
  
• "In internal medicine residents, we also found the weakest skill is patient education. We are hoping to expand our program to other residencies and sites soon and focus on some out-patient patient safety issues."
• If you want to find more about some of Dr. Sandy Zabar's (NY University) group educational innovations please check out http://prmeir.med.nyu.edu.

Work in progress: Vote on my poster layout

I'm getting my poster for next week's CORD conference ready. I'm sending to Kinko's tomorrow. I hope it doesn't cost me an arm and a leg at 30''x40''. Which design do you prefer?

Any suggestions welcome in the Comments section.

Poster #1: White background, yellow banner

Poster #2: Blue background, yellow banner

Poster #3: Blue background, white banner

Poster #4: White background, white banner

Article review: Learning in a chaotic environment

Most great education articles can be found on PubMed. On occasion, however, one falls through the cracks and only appears in the ERIC database (Education Resource Information Center). Such is the case of a fascinating qualitative education article on how EM residents learn in a chaotic environment such as the Emergency Department. It also taught me a lot about how a good qualitative study should be conducted.

Background
Emergency Departments are a prime example of a chaotic work environment with unpredictable workloads and frequent interruptions. It is also a rich environment for learning because of the large volume of patients of varying acuity. Traditional factors which support teaching and learning in the ED follow an "apprenticeship perspective" model and include:

• Having supportive supervisors and a supportive learning environment
  
• Getting feedback
• Having enthusiastic teachers
• Having supervisors who actively engage the learner
  

Previous studies are either teacher-centric or focus on what the learners feel about teaching. This study posed the unique question: How do learners feel that they learn in the chaotic ED setting?

Methods
Semi-structured interviews of 12 volunteer EM residents (6 PGY-1, 4 PGY-2, and 2 PGY-3), lasting about 60-90 minutes, were audiotaped and transcribed. Interviews were conducted by 2 non-physician research team members. Initial data analysis was conducted by 3 non-physician team members. The de-identified data was reviewed by 2 emergency physicians team members for credibility and reliability.

Results
The interviews revealed 4 types of learning "episodes", or activities/events where learning occurred.

1. Participation in the environment

• In the day-to-day experience of working in the ED, learners get to manage multiple patients, confer with others, and participate in formal education.
• Facilitators (or triggers) for learning: Understanding expectations of resident role, volume of patient cases, observation of role models, eliciting feedback, developing self-awareness
  

2. Focused learning moments

• Short, focused learning moments of something specific
• Usually involves learning from another source (attending physician, colleague, consultant, reference material)
• Facilitators (or triggers) for learning: Directed teaching activities (brief clinical tips, procedure pearls), self-directed activities

3. Repetitive cycles

• Learning from repeated occurrences of the same patient symptom or situation
• Facilitators (or triggers) for learning: Practicing the management of a disease or situation multiple times, self-reflection, followup of self-directed activities

4. Intense experiences

• Experiences involving an interpersonal exchange between the learner and another healthcare professional (attending physician, nurse, consultant) involving patient management
• Facilitators (or triggers) for learning: Difficult cases, learner-centered concentrated teaching, first time in managing a particular case, mistakes
  

Many of the learning "episodes" are interconnected. One event may trigger multiple learning episodes. This learning may start in the ED but learning continues often times outside of the ED "cloud" when reading at home or discussing with colleagues. This might appear something like the above schematic showing the learning process of EM residents.

Interestingly, most participants commented that while attending physician teaching and the learning environment are important, the key to successful learning involves self-motivation, self-direction, and reflection.

Conclusion
Learning in chaotic learning environments can be categorized into 4 categories: participation in the ED, focused moments, repetitive cycles, intense experiences. These can occur under the same clinical circumstance and do not follow any hierarchical pattern.

Specifically in chaotic environments, it is essential that learners take responsibility for their own learning, identifying gaps in knowledge, seeking feedback, and working towards closing these gaps. Learning occurs both within and beyond the ED setting.

The table below summarizes how the residents and attendings can maximize learning in the chaotic ED environment, based on EM residents' perspectives.


One useful trick that I try to use when supervising residents, which is applicable to several types of learning is-- verbalizing my thought process in patient management decisions. This helps learners understand how I got from point A to B to C ... to H. I even go as far to describe my decision tree. "If this test is negative, I'm thinking..." and "if this test is positive, I will consider doing..."

This study is unique in that it shifts focus from "what can an attending physician do to improve the teaching of EM residents?" to "how do EM residents learn in a chaotic environment?" Understanding the individual and social context of learning in the ED can help optimize learning and teaching.

If you have trouble finding this article, feel free to email me for a copy.



Resource
Goldman E, Plack M, Roche C, Smith J, Turley C. Learning in a chaotic environment. Journal of Workplace Learning. 2009; 21(7):555-74.

Paucis Verbis card: Ankle fractures

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你讲英语?
هل تتحدث الانكليزية

Ankle fractures are a common injury diagnosed in the Emergency Department. Being able to speak Ortho-ese (i.e. the language of orthopedists) is invaluable in consulting the orthopedist over the phone. One ankle fracture classification system that our orthopedists like to use is the Lauge-Hansen system.

In this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is the Lauge-Hansen classification of ankle fractures.

Feel free to download this card and print on a 4'' x 6'' index card.
[MS Word] [PDF]

See other Paucis Verbis cards.

iPhone uses in the Emergency Department

Occasionally, I get a rare - "Hey congrats on the article!" comment from residents or students. It's usually in reference to my ACEP News column that comes out every 3 months on Tricks of the Trade. However, I got about 3 shout-outs in the past 2 days. How odd.

Then I saw one of our office staff who was reading EM News. "Hey cool!" she said. Totally confused, I realized that I was quoted on the front page of this week's publication about iPhone applications in EM. Many months ago, I had done a brief telephone interview with the writer.

I'm thrilled that Dr. Eric Silman, a UCSF-SFGH resident, got a shout-out since it's his ACEP News article that sparked this piece. Unfortunately, now more people know how nerdy we are. Great...

Here's the link:
http://journals.lww.com/em-news/Fulltext/2010/02000/Take_Two_Apps_and_Call_My_iPhone_in_the_Morning.1.aspx

Trick of the Trade: My new penlight

On any given day in the ED, I use my super-bright penlight 2-5 times a day. It is amazing what things I've almost missed without a bright LED flashlight.

• Subtle HSV-2 labial ulcerations in a female patient with dysuria
• Additional scalp lacerations hidden in the hair
• Tonsillar exudates in a patient with strep pharyngitis
• Unequal pupillary responses in a brightly lit trauma room in a head-injured patient

I wanted to revisit a prior post about the importance of changing your Tungsten penlight to a LED light.

There apparently is a whole world of LED enthusiasts, debating and talking about the latest and greatest in LED technology. There is constant competition amongst companies to generate the most efficient and brightest lighting.

Although I have no clue about this topic, it's nice to have techie friends who do! It's how I found out about the company 4Sevens and the Preon flashlight. (I do not have any financial affiliations with 4Sevens, besides the fact that they have my $49 for purchasing the penlight.)

The XP-G LED light, developed by the company Cree, can emit a super bright light with minimal power requirement. The company 4Sevens has developed the first AAA-battery powered Cree XP-G LED penlight, called the Preon flashlight. Most kits, which vary based on the outer shell color, are currently on back-order because of the recent release and great press about the flashlight kit.


I just got my red Preon kit in the mail and the light is indeed "absurdly bright", as the website touts. It fits nicely in my scrub top pocket because it really is the size and shape of a pen. Also, it takes commonly available AAA batteries, which I have in rechargeable form.

When you order it, it comes in a set. You can assemble a short 1-AAA battery penlight, or attach a longer barrel to build a brighter 2-AAA battery penlight. There are 3 settings - low, medium, and "ack! I'm blinded" high just by lightly tapping on the clicker.

Check out how much light this little penlight emits in a dimly lit room!

So, I retired my recent LED light, which was the size of a roll of quarters and could fit easily in your palm. I've always loved its bright output. The problem was that I didn't have a great way to carry it. It was too bulky for my scrub top pocket. And when I kept it in my scrub pants back-pocket, I would often accidentally sit on it and turn it on. My butt would be aglow for hours before anyone told me! A waste of a pricey lithium battery.

What did I do with my old penlight? I passed it along to an uber-enthusiastic EM resident who was always admiring the penlight whenever I used it. When I gave it to him, he was so over-the-top excited that I felt like I was passing him the Olympic torch or something.

Work in progress: Global health conference poster

Every once in a while I have to pinch myself, because I never envisioned myself working in the area of Global Health. It's amazing/crazy what opportunities come to you, if you just hang out with creative, collaborative, passionate, and hard-working people.


This past year, I went on a KidsCareEverywhere trip to Vietnam where we hosted an educational conference in Hanoi, teaching Vietnamese pediatricians how use a medical software (PEMSoft) to improve their care of kids (prior blog post). We embedded a pre-test/post-test research study question. How well do pediatricians improve their clinical knowledge after spending 3 hours learning an English-based medical decision support software?

We recently got the abstract of our study accepted into the 12th Annual Bay Area International Health Interest Group Conference, hosted by UCSF Global Health Sciences on March 7, 2010. It is at Cole Hall on the UCSF campus. We are working on the poster layout this week.

Effect of Decision Support Software on the Clinical Performance of Vietnamese Physicians
Dieckmann MG, Sharp J, Lin M, Dieckmann R

Introduction
Vietnamese physicians have limited access to current medical references and “decision support” tools. Lack of availability of current information contributes to preventable morbidity and mortality. While most Vietnamese hospitals have computer systems, no previous study has evaluated the impact of computer-based medical decision support on Vietnamese physician performance. A nonprofit organization, “KidsCareEverywhere”, donates computerized decision support software to public hospitals in the developing world. In September 2009, KidsCareEverywhere, sponsored by the “UCSF Vietnam Working Group”, installed such software in Vietnam’s National Hospital of Pediatrics. The team trained the physicians in using the software, then evaluated the effect of the software on physicians’ clinical decision making skills.

Methodology
All training materials were translated into Vietnamese to attain clarity, although the medical software content remained in English. Before the training, half of the study group received one set of cases on common pediatric emergencies, and the other half received a similar but distinctly different set of alternative cases. Subjects were asked to use any familiar references on pediatric emergencies to answer the pre-test questions. After the training, the physicians used the computer software to answer the post-test questions. Each cohort was given the alternative set of cases for the post-test. The primary outcome measure was the change in test scores.

Results
This prospective, randomized crossover study of 54 physicians demonstrated a 61% improvement on test scores, assessing common pediatric emergencies (p < 0.0001).

Discussion
Computer-based, English language decision support software offers an effective tool for Vietnamese physicians. Vietnam is a fertile site for this form of information support, due to extraordinary need, dramatic increases in computer availability, and the familiarity of physicians with English medical terminology.

Acknowledgements
We would like to acknowledge the invaluable assistance provided by UCSF Vietnam Working Group and the KidsCareEverywhere Board of Directors.

Article review: Measuring multitasking abilities

What is multitasking ability?

How do you measure it?

Emergency physicians epitomize what it's like to work in a time-pressured, interruption-based environment. Multitasking is necessary to survive in this environment where you are constantly shifting focus and addressing new tasks or problems as they arise.

EM residency programs focus a lot on teaching and evaluating medical knowledge, but how can they teach and evaluate residents in the equally important area of multitasking?

There exists a Multi-Tasking Assessment Tool (MTAT), developed to assess job performance of professionals working in a multitasking environment such as military personnel and pilots. This online tool gives the user three 5-minute multitasking tasks to complete.

Study
In this prospective study, 35 EM residents from a single residency program took the MTAT test. Their scores were compared to an indirect marker of clinical work efficiency (average relative value units (RVU) per hour over a 6 month period). A high RVU suggests an efficient resident. The MTAT score correlation with RVUs were controlled for year in training and the in-service training exam score.

Results

• Year in training and MTAT score accounted for 68% of the variance seen in resident RVU efficiency. Of that 68% variance, year in training was far more correlative (87%) than the MTAT metrics (13%).
• The in-service training exam score, as an indirect marker of medical knowledge, did not predict RVU efficiency.
  
• MTAT scores did not differ significantly for the first, second, and third year residents.
  

What does this mean?

• Although minor, MTAT scores may provide some predictive value in clinical work efficiency.

Lingering questions
While it is a cool finding that MTAT scores may slightly predict RVUs for residents, this study brings up more questions:

• Is RVU the best measure of efficiency?
• Can high MTAT scores predict other things besides efficiency, such as how well residents might deal with the stress of interruptions and multitasking? Are emergency physicians with low MTAT scores more at risk for "burn out"?
  
• How does one learn how to improve one's MTAT scores?
• Is there a role for MTAT testing during medical school to help students in choosing their specialty?
• Is there a role for MTAT testing for nursing students considering working in an ED?
  

An idea
Access to the MTAT test unfortunately costs about $10 per test at www.multitaskingtests.com. Perhaps someone in EM should develop an open-access validated test to measure multitasking for EM residents and attendings. Hmm.


Reference
Ledrick D, Fisher S, Thompson J, Sniadanko M. An Assessment of Emergency Medicine Residents’ Ability to Perform in a Multitasking Environment. Acad Med. 2009; 84:1289–1294.

Paucis Verbis card: Urinary tract infection

In this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is Urinary Tract Infection. UTIs are one of the most common infections that we treat in the Emergency Department.

San Francisco General Hospital's
2008 antibiogram for urinary bacteria

(Click to see larger view.)

E. coli isolates at SFGH have a resistance rate to TMP-SMX and ciprofloxacin of 32% and 15%, respectively.

Feel free to download this card and print on a 4'' x 6'' index card.
[MS Word] [PDF]

See other Paucis Verbis cards.

Beware the hidden tibia plateau fracture

Find the fracture in this patient with blunt knee trauma.

As a general rule, plain films are insensitive in ruling out orthopedic injuries. One particularly tricky area is the knee. This 2-view knee series above is normal.

Did you know that the sensitivity of picking up knee fractures is as low as 79% with a 2-view series and 85% with a 4-view series? With the advent of CT imaging, more and more subtle fractures are being found.

Here is the same patient with 2 oblique views:

Although oblique views add more sensitivity in detecting fractures, these are also normal. However in the CT reformats of this patient's knee, the fracture becomes obvious - a depressed lateral tibial plateau fracture.

Beware the "invisible" tibial plateau fracture on plain films!

CT image the patient's knee especially if unable to bear weight after significant blunt trauma, despite plain films.

Trick of the trade: Minimizing post-LP headache

Have you ever performed a lumbar puncture (LP) in a patient, only to have them return the next day for new debilitating headaches? It's worse when sitting up, and much improved when laying down. You hate adding more problems for the patient, put you are certain that s/he now has a post-LP headache.

What causes a post-LP headache?
It's a headache after a LP, presumably because of a persistent CSF leak from the puncture site.

How can you minimize the risk of a post-LP headache?
There are several techniques you can used, as summaried in a 2006 JAMA article:

1. Use an atraumatic, blunt needle.

• The standard LP needle has a cutting edge. A non-cutting needle requires a small scalpel nick in the patient's skin before inserting the blunt needle.
  
• The incidence of post-LP headaches MAY be decreased (OR 4.6, range 0.19-1.07), because it doesn't actually cut any dural or arachnoid fibers.
  
• Balance this with the fact that 3 studies show a trend towards an increased number of attempts required with the atraumatic needle. Personally, I don't use a blunt needle.
  

2. Use a smaller gauge LP needle.

• A smaller gauge (26 gauge vs 22 gauge) needle yields fewer post-LP headaches with an absolute risk reduction of 26%.
  
• Next time, look at what size LP needle comes in your LP kit. Consider using a smaller gauge.

3. Reinsert the stylet in the needle prior to needle removal

• This causes fewer post-LP headaches with absolute risk reduction of 11%.
• The theory is than arachnoid strand may flow into the needle during CSF collection. Removing the needle without the stylet may "pull" the strand through the dura, causing a persistent CSF leak.
  

Reference
Straus SE, Thorpe KE, Holroyd-Leduc J. How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis? JAMA. 2006;296:2012-22.

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.