Tricks of the trade: Anesthetizing the nasopharyngeal tract

Nasogastric tube placement is one of the most uncomfortable procedures in the Emergency Department. Why can't we find a painless way to do this?

Now that I am doing more fiberoptic nasopharyngoscopes, this issue is coming up more and more frequently. I've been using NP scopes mainly to check for laryngeal edema in the setting of angioedema. These recent photos visualize a normal epiglottis and normal laryngeal anatomy, respectively.



Tricks of the trade: Anesthetizing the nasopharyngeal tract
There is no pain-free way to place NG tubes and insert NP-scopes, but this 2-step approach worked amazingly well in my last patient in whom we performed a NP-scope.

Nebulized lidocaine:

I use 4 cc of 4% lidocaine in a nebulizer unit and face mask.

Viscous lidocaine:

I inject about 5 cc of 2% viscous lidocaine into a nostril.
The patient "snorts in" the lidocaine.

Yes, this 2-step process takes a little more time. If time permits, these extra few minutes are worth it. Just be sure to perform the procedure immediately after the nebulizer treatment is completed. The topical lidocaine wears off quickly.

What techniques do you use?

Great teaching video: Corneal FB removal

Patients often come into the ED for eye pain. One of my favorite procedures is removal of a small foreign body embedded in the cornea. There is a great instructional video on removing such foreign bodies and the use of a ophthalmic burr on removing rust rings.

The video recommends using either a 30-gauge or 18-gauge needle. I prefer the less innocuous-looking 29-gauge insulin/TB needle. Can you imagine someone coming towards your eye with a large 18-gauge needle?!

Go to video link.

Article review: The future of EM

As I was perusing through a recent Academic Medicine journal, I came across this interesting perspective piece on Emergency Medicine, written by national leaders in our specialty.

This article essentially states that how the nation addresses ED crowding will define the future of EM. Currently, Emergency Departments are at a breaking point where overwhelming demands are commonly placed on under-resourced practices.

Ten years ago, a SAEM task force accurately forecasted the following about the specialty of EM:

• The increasing importance and growth of electronic information systems
• A larger ED volume with greater numbers of elder patients
• Growth of home care, telemedicine, and EM research

The task force, however, did not predict the phenomenon of having ED boarders (patients staying in the ED for many hours awaiting an inpatient bed). Also their prediction that there would be greater health insurance coverage has not yet come true.

This article posits three different scenarios for the future of EM, from a pessimistic, optimistic, and realistic perspective:

Pessimistic - "It's all about the money."
For ED's where uncompensated care is common, the financial stressors will be too much. These ED's will close down. To save on personnel costs, emergency physician salaries will drop. Also, many will be replaced by mid-level providers (NPs, PAs) in many rural and some urban areas. Patients seeking acute medical care may essentially just get triaged in the ED to other places for further care. This decreases the likelihood that medical students will want to pursue a career in EM.

Optimistic - "It's all about the quality of care."
More important than the excessive costs of health care are patient outcomes and the quality of care. Hospitals and/or politicians will solve the ED boarding problem and focus on optimizing the ED's ability to address key time-sensitive disease processes (acute MI, sepsis, stroke, trauma, etc). The ED will become the central diagnostic and treatment hub for all out-of-hospital care. The Internet will play a major role in this, including the use of telemedicine technologies. EM will play an even more critical role in health care than it already is.

Realistic - "It's about the money AND quality of care."
Our specialty of EM will have to demonstrate that improving quality of care ultimately results in long-term cost savings. ED observation units will be more common, as a means to reduce inpatient costs. Electronic medical records and health information systems will play a critical role in optimizing care and minimizing costs. The continued incorporation of physician extenders (NPs, PAs) will reduce overall physician workforce requirements. And lastly, emergency physicians may also find themselves "outsourced" in a "boutique medicine" fashion -- that is -- practicing EM in workplaces, malls, and hotels.

Oooh. I want to work at Google, if they have a spot.

Reference
Sklar DP, Handel DA, Hoekstra J, Baren JM, Zink B, Hedges JR. The future of Emergency Medicine: an evolutionary perspective. Acad Med 2010; 85:490-5.

Paucis Verbis card: Angioedema

Image source: AllergyCases.org

Recently, a patient presented with angioedema after starting taking an ACE-inhibitor. There was upper lip swelling, similar appearing to the case above. He also experience a hoarse voice. Before the advent of fiberoptic nasopharyngoscopy, it was assumed that there may be laryngeal edema. Fortunately, using technology, we were able to visualize a normal epiglottis and a grossly normal laryngeal anatomy.

An example of an abnormal nasopharyngoscopy image is shown below with a slightly edematous epiglottis, normal vocal cords, and normal arytenoid cartilage.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Angioedema.

The 1999 study on admission guidelines, of course, should be weighed with physician judgment and the patient's social issues. The study was retrospective and the results should be weighed carefully. For me, generally I admit all intraoral angioedema cases and progressively worsening extraoral angioedema. I also perform fiberoptic nasopharyngoscopy on all patients with voice changes.

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

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Poll: Evaluation anonymity

As educators, we are constantly being asked to complete evaluation forms for medical students and residents. Most are in the form of formative evaluations. That means that you are giving the learner frequent feedback (like a coach) so that they can do better in the immediate future. This is in contrast to summative evaluations, which are conducted for the purposes of "grading" the learner.

More and more institutions are moving towards a daily post-shift evaluation of medical students and residents rotating in the Emergency Department. This is often done online. There are pros and cons for having the evaluations be anonymous.

PROS (for anonymity)

• Faculty may avoid giving negative feedback to learners for fear of awkward interactions on future ED shifts.With anonymous evaluations, faculty may feel more comfortable giving constructive criticism.
  

• If faculty avoid giving constructive criticisms (or at least very watered down) in non-anonymous evaluations, problem issues may go undetected longer because no one comments on them.

CONS (against anonymity)

• Medical trainees are adult learners and should be adult enough to hear direct feedback.
• Knowing who the evaluation is from allows for more direct discussion of specific cases or scenarios.

What do you think should be done?

Comments are welcome to explain your reasoning from the perspective of a learner or educator.

Trick of the trade: Ear foreign body extraction

A 6-year old boy has placed a hard bead in his ear and presents to the ED for care. How do you remove this foreign body as painlessly as possible? You can just barely see the edge of the bead by just looking at the external ear.

By experience, you know that mini-Alligator clips and forceps will not be able to sufficiently grab the edges of the bead. Additionally it may push the bead in even further.

Trick of the Trade
Tissue adhesive glue to the rescue!

Apply the glue gently to a long Q-tip's wooden end. Immediately adhere the stick to the bead, being careful not to touch the external ear canal. This should be a painless procedure. In fact, I was showing the child some animation movies during this part of the procedure. After waiting 20-30 seconds to let the glue dry, my resident gently rotated the bead to loosen the bead from the canal edges. Then like magic, he pulled the bead out with only a little "ouch" voiced by an otherwise calm child.


Just as equally entertaining was the pediatric resident doing a little happy dance. Wish I had gotten a photo of that.

Note: This technique should only be reserved for the child who can stay still and for hard-surface objects. For instance, it won't work on organic products such as peas, corn, or cockroaches.

Work in progress: How can you balance ED crowding and education?

I'm working on writing a CORD consensus article on the impact of ED crowding on education and innovations towards maintaining educational excellence. We posited 2 scenarios of ED crowding:

• Overwhelming numbers of active ED patients
• Many ED boarders who are awaiting inpatient beds and who are taking up rooms which normally would have been used to see new patients

What approaches do you know of which improve the ED educational experience for learners? We have thus far categorized innovations into 3 areas:

1. Change on the individual educator level

• Improving faculty and resident development skills (bedside teaching, feedback, frame teaching in reference to competencies)
• Reinforce to faculty that they are teaching all the time – it’s not all about pathophysiology
• Resident teaching shifts
• Attending teaching shifts
• Incorporating affiliated staff to teach (pharmacist, social worker, nursing)
• On-hand teaching tools (cards, videos, xrays)
• Start a teaching file or find an online resource
• Daily protected time on shift for teaching (AM teaching rounds)
• More frequent rounds (rapid-fire group learning on patients)
• Teaching off-shift (feedback on documentation, reflective portfolio)

2. Change on the individual learner level

• Reset expectations of learner
• Learner takes more active role in identifying educational focus (eg. Start of shift - What do you want to work on today?)
• Be obvious as the educator (“This is the teaching point from this case…”)
• Senior resident role to include management of crowding issues (screening labs, flow management)

3. Change on the systems level

• Redefining and increasing role of off-service ED resident (Procedures or Sedation resident in ED)
• Admin resident participation on Crowding QI committee
• Inpatient staff to care for boarded patients while in ED (frees up ED staff)
• Improving resident efficiency (role for ED scribes?)

Any other ideas for innovations or approaches to maintain educational excellence in crowded EDs? Crowding isn't going to be fixed any time soon, and we (as educators) must innovate and adapt.

Article review: The next 10 years in medical education

Abraham Flexner

"Medical Education in the United States and Canada in 1910" was a landmark article, published by Abraham Flexner in 1910. It's commonly referred to as the Flexner Report. It revolutionized medical education in its call for higher quality and standardization.

In summary the report advocated for the improvement of medical education and medical schools in 4 areas:

1. Standardization: Because educational curricula varied widely in content and quality across medical schools in 1910, students were trained with variable success. The Report recommended having 4 years of college and a set list of science courses as a prerequisite. Furthermore, the medical school would offer a 2+2 curriculum and would answer to an overarching accreditation body.

2. Integration: Before 1910, medical students received limited experience with science, laboratory work, and direct patient care. The Report recommended the incorporation of laboratory learning into the curriculum and the expansion of the curriculum to incorporate 2 years of clinical training.

3. Habits of inquiry and improvement: Before 1910, medical students learned based on rote memorization and tradition. The Flexner Report recommended that students are trained to "think like scientists". To do this, teaching should be conducted by scientifically trained faculty in the university and clinical setting.

4. Identity formation: Before 1910, the faculty educators were of variable quality. The Flexner Report recommended moving medical education into the university setting and culture, where university-based faculty can serve as role models for students.

This commentary article advocates for a new "Flexnerian" shake-up in medical education thinking. What's in the future? This includes focusing on the following 4 goals for the next 10 years:

1. Develop new partnerships to build medical education systems that support lifelong learning principles. Specifically, experts in asynchronous education and technology are needed.

2. Interdisciplinary education and team learning are critical to improve communication and cross-collaboration. This means educational partnerships with nursing, pharmacy, and public health. I would even say that this should also extend to global health and instructional technology departments.

3. Medical school curriculum revamping. The current curricular model needs to be re-looked at in its entirety. The AAMC and other accreditation organizations need to consider building a competency-based curriculum that would allow learners to tailor their own education time.

For instance, if I performed average in the Anatomy, Cardiovascular, and Pulmonary modules, but aced the Statistics and Renal modules, I would spend more time on the former and much less time on the latter. This may result in some students not needing all 4 years to complete medical school. Radical thought -- I love this concept.

4. Put a cap on medical student tuitions. Financial woes of medical schools and universities shouldn't trickle down to the students. Funding allocations should be transparent in order to come up with sustainable solutions to medical education funding.

Thoughts?


Reference
Skochelak SE. A Century of Progress in Medical Education: What About the Next 10 Years? Acad Med 2010; 85:197-200.

Paucis Verbis card: Knee exam

How accurate is the clinical knee exam?

JAMA published a meta-analysis trying to answer this question. Although they include patients with acute and chronic knee pain, it's a good general review of the knee anatomy, historical clues, and exam elements.

In the ED, the knee exam is challenging because we see very acute injuries where knee pain and swelling often preclude an accurate exam. For patients with an equivocal exam, be sure to refer for orthopedic follow-up. A repeat exam should be performed once the pain and swelling subside.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews the Knee Exam.

I used to be all confused and had a hard time memorizing all the different maneuvers (especially for the meniscus). It is much easier to remember after doing these knee exams routinely.

Particularly, the lateral pivot test and McMurray test can be done with several rounds of simultaneous knee flexion-extension, internal-external rotation, and valgus stressing. Looking at diagrams almost makes things more confusing.

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

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Inspirational video: Start hustling

Do you ever feel that you are stuck in a rut at work? This video is a great pick-me-up, booster shot in re-energizing your work life. Warning - some adult language.

This is a video featuring Gary Vaynerchuk, a self-made success story who initially built his business and brand by creating Wine TV - a daily video blog demystifying the historically stuffy subject of wine. More uniquely, he has become an entertaining speaker who gives insightful points, which are universally relevant to anyone who is passionate about a niche, project, or concept.

So whether you are interested in building your niche in international disaster medicine, creating a new blog, or starting a new business, what are you waiting for? Get up and get going.

Basically, the secret to success? Hard work and hustling.

Tricks of the trade: Chemical sedation options

You walk into a room where a patient is screaming and thrashing about in his/her gurney from some stimulant abuse. PCP, cocaine, methamphetamine... or all of the above.

When the number of people (police officers, security guards, nurses) is greater than the patient's pupil size, you KNOW that you'll need some chemical sedation.

What intramuscular sedation regimen do you use?

Regimens for chemical restraint vary by institution. Before droperidol was black-boxed by the FDA for allegedly causing QTc prolongation arrhythmias, it was widely used. I called it "vitamin D". What a wonderful single-agent medication. It's really debatable whether the black-box label was justified.

• HAC: Haldol 5 mg, Ativan 2 mg, Cogentin 1 mg IM all in 1 syringe

• Midazolam (versed): 5 mg IM single agent - This is a very short acting benzodiazepine which is more consistently absorbed intramuscularly than lorazepam (ativan).

• B52: Haldol 5 mg, Ativan 2 mg, Benedryl 50 mg IM

• Haldol: 5 mg IM single agent

I prefer either HAC or versed alone (if I need something short-acting and don't think I'll need the antipsychotic effects of haldol).

What regimen do you use?

Work in progress: Poster on blogging

(Click to enlarge draft of poster)

I need your help with a project!

My poster on blogging was accepted to the annual UCSF Academy of Medical Educator's Education Day. Feelings of joy and validation were quickly followed by terror and inadequacy.

In order to get my poster costs reimbursed, I have to get feedback from my co-authors and incorporate that feedback into the poster. As you can see from the poster title on top, I have no co-authors! Since you are all my virtual co-authors, I thought I'd solicit for comments and suggestions.

FYI: I put out in shout-out to the EMCrit Blog, The Poison Review, and Life in the Fast Lane in the Background section to make me sound more legitimate. Hope you established bloggers don't mind!

Two questions that the reviewers wanted me to address were:

1. The use of the worldwide web for information dissemination and information exchange has far reaching impact, however, the quality of information posting and discussion remains to be major limitations in the method of teaching. How would you propose to address the quality of posting in the process?
2. This is original and creative work and a great blog. I do wonder what medical education principles guided the content and whether there was any thought about learner objectives and educational outcomes?

Any thoughts would be very much welcome.

I ask in the hopes that it won't be a Ferris Bueller movie moment (a.k.a. awkward silence, followed by "Anyone? Bueller... Bueller... Bueller?").

Article review: ED crowding and education

"The effect of ED crowding on education"

My heart almost stopped when I read this article title in Amer J of Emerg Med. This was the premise of my recently completed study - using a prospective, time-motion methodology. I'm in the process of writing the manuscript. Did I get scooped by my friends at U Penn?

Whew. Fortunately, no. Different methodology.

This study was a cross-sectional study looking at learner assessment of education, using a validated tool called the ER (Emergency Rotation) Score. The results are interesting.

The problem
We know that ED crowding negatively impacts clinical care. How does it impact our teaching of medical students and residents? The ED is traditionally known as a great place for learning how to resuscitate high-acuity patients, to manage and risk-stratify undifferentiated cases, and to perform procedures. Experientially, I feel like I teach less when it gets extremely crowded.

Methodology
Over a 5-week period, 43 residents and 3 medical students prospectively assessed 34 attendings using a simple ER Score tool. There were 352 separate encounters. This validated tool assessed the attending based on 4 domains (teaching, clinical care, approachability, helpfulness) with each domain assessed on a 5-point scale. The scores were correlated with crowding measures (waiting room number, occupancy rate, number of admitted patients, and patient-hours).

ER Score tool

What was their enrollment scheme?
Upon arrival, the research assistant selected the patient with the most recent admission order where the learner-attending pair was still present in the ED. The learner was asked to fill out the ER Score tool. For each admitted patient case, the research assistant also enrolled a non-admitted patient with a similar triage intake time. The learner for this non-admitted case was also asked to fill out the ER Score tool. The study group intentionally structured this methodology to oversample admitted patients, which they assumed impacted education more than non-admitted patients.

Results
The median score was 16 of 20. ED crowding levels were NOT associated with ER scores or their individual domains.

How fascinating that learners still felt that the quality of teaching and learning in the ED was maintained despite the ED being overwhelmed beyond capacity.

The next step is to follow Kirkpatrick's model in conducting educational research. In this model, satisfaction/reaction-based studies are the first (lowest) tier. Such studies inherently have flaws based on bias, recall, and halo effect. The next study is to look at more objective measures assessing the impact of crowding on education. Hmm, I better get going on my manuscript.

Kirkpatrick's 4-tiered model to evaluate training and education

Reference
Pines JM, Prabhu A, McCusker CM, Hollander JE. The effect of ED crowding on education. Amer J Emerg Med (2010) 28, 217–220.

Paucis Verbis card: Hyperkalemia management

Hyperkalemia is a common presentation in the Emergency Department, especially in the setting of acute renal failure. In one shift, I had 4 patients with hyperkalemia! All had from some form of renal failure.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews the treatment options for hyperkalemia.

For easier readability, here's the table rotated (click to enlarge):

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

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TEDMED talk on wireless technologies in medicine

TEDMED is an offshoot of the inspirational and widely popular TED talks (Technology, Entertainment Design). TEDMED talks focus on all things medicine as we look to the future.

One talk caught my eye because of my interest in the area of technology and medicine. Dr. Eric Topol, a cardiologist, gives us a glimpse of what is already happening now and in the very near future with wireless technology.

Real time vital signs, EKG readings, EEG readings, and glucose levels are currently technologically possible both for home use and in the clinical setting. Real time data capture and transmission of this information onto your peripheral handheld device is going to revolutionize the entire spectrum of preventative medicine, primary care, inpatient care, and emergency medicine.

Handheld mobile devices are taking over the world, and wireless healthcare monitoring is where it's at.

Hmm, maybe I should invest in battery technology. How's all this going to be powered?

Trick of the Trade: Minimizing abscess odor

Building on my theme of combating odors in the Emergency Department (see Toxic Sock Syndrome), foul-smelling pus from large abscesses has got to be one of the most nauseating smells in the ED for me.



How can you minimize such odors?

• Prepare a Yankauer wall suction set up.
• Start by making only a small initial incision in the abscess, such that you can fit the Yankauer tip in the opening.
• Suction out as much of the pus into the closed suction canister as possible.
• Widen the incision and continue suctioning out the pus, as needed.
  

Basically you are moving the smell from one closed system (the abscess) into another closed system (wall canister).

What tricks do you have to minimize odors when performing I+Ds of abscesses?

EM blogger roll call

How do I keep up with the information from the myriad of Emergency Medicine websites out there? Blogs, Twitter, Journals, oh my.

Thanks to LifeInTheFastLane, you can check out all the current EM bloggers out there with their Twitter name and RSS feed links! I had no idea there were so many. I can appreciate how much time and effort it took to compile this list. Fantastic job, guys.

Also coincidentally, the folks over at Webicina.com just developed a one-stop shopping website that lists many of the same EM blogs as LifeInTheFastLane has. It is definitely worth checking out. This site breaks down EM-related information into:

• EM Journal Table of Contents
• EM Blogs
• EM News
• Web 2.0 Tools - Has Twitter real-time posts

Not sure how I made all of these lists, but I really need to watch what I write and tweet! I'm flattered and will try to keep to keep the content as useful and innovative as possible. Any feedback for improvement would be welcome.

Article review: Tools for Direct Observation

Direct observation of medical students and residents provides educators with evaluative information about the learners' knowledge base, clinical competency, and behavioral practices. This JAMA article is a systematic review of direct observation tools and their validity. Over 10,000 studies published during 1965-2009 were assessed.

If you are trying to develop your own direct observation tool, take a look at this article -- It may help you find a template that you might be able to morph into something applicable to your practice.

Total # of tools identified = 55

• 21 focused on medical students, 32 focused on residents/fellows, 2 focused on both
  
• Only 11 had evidence of internal validity and validity based on relationship to other variables
  
• Strongest validity evidence has been established for the Mini Clinical Evaluation Exercise (mini-CEX)

The authors assessed 5 areas of validity in each of these tools:

• Content validity - did the instrument measure the intended domain of content?
  
• Response process - were the raters properly trained?
  
• Internal structure (reliability) - consistency of the results using the same instrument
  
• Relationship to other variables
• Outcomes

Bottom line
Very few tools were thoroughly evaluated and tested for validity. Most tools assessed the learners' and observers' experiences with the tool rather than learning or clinical outcomes.

Furthermore, only a few studies adequately performed and documented the observer training process. This is just as important as the structure and content of the evaluation tool. If you aren't accurately capturing the data that you intended, your results are useless. Garbage in, garbage out.

Author comments
This was an article presented at "Education Journal Club" at the recent 2010 CORD Academic Assembly that Dr. Sorabh Khandelwal (the Ohio State Univ) and I co-ran. Sorabh contacted the author, Dr. Jennifer Kogan (Univ Penn), informally to solicit post-publication insight and comments. Dr. Kogan graciously shared some of her thoughts.

• This area of educational research in developing direct observation tools may be "stuck" at this time.
  
• There is no perfect direct observation tool.
• Faculty development needs to include how to use a direct observation tool. This is critical. The training process needs be a drip rather than a bolus approach. Frequent and periodic re-calibration feedback should be provided to the faculty members to minimize inter-rater variability.
  

Reference
Kogan JR, Holmboe ES, Hauer KE. Tools for direct observation and assessment of clinical skills of medical trainees. JAMA. 2009;302(12):1316-1326

Paucis Verbis card: Aneurysmal subarachnoid hemorrhage

Left anterior communicating artery aneurysm
and subarachnoid hemorrhage

Atraumatic subarachnoid bleeds are most commonly caused by ruptured intracranial aneurysms.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews the current management, knowledge, and challenges in aneurysmal subarachnoid hemorrhage (SAH).

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

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Insights into mentorship for faculty

No matter where you are in your training and career, mentorship is important (even for faculty). How do you navigate the waters of medical school, residency, and the specialty of academic Emergency Medicine?

Finding a mentor is key. UCSF just released a videotaped panel session, where star mentors and leaders gave their perspectives and experiences around mentorship.

The video is around 86 minutes long. If pressed for time, you can skip through the first 13 minutes or so (housekeeping issues and introductions).Unfortunately, this Flash-based video doesn't have a timed scrubber at the bottom, which allows you to fast-forward exactly to particular time-points in the video. Just eye-ball it.

In the second half of the video, they focus on differentiating between a manager (who sets goals and expectations - more like a referee) and a mentor (who is more like a coach).

What lessons have you learned in your mentorship experiences (either as a mentee or mentor)? Feel free to comment.

Trick of the trade: Irrigation scalp wound photos

I mentioned from an earlier post about building a "head basin" for collecting irrigation fluid prior to wound closure. This basin prevents a deluge of fluid from soaking the gurney sheets and patient.

I finally managed to capture this trick in action, while a student was irrigating an eyebrow laceration.

Pearl: When cutting out a semi-circular or rectangular hole in the basin, be sure that there remains a 2-4 inch lip at the bottom to ensure that fluid can collect in the basin.

Great teaching video: "Cell and flare"

Using the slit lamp can be a challenge to learn, especially if you haven't seen pathology before. In checking for anterior uveitis (i.e. iritis), you need to look for "cell and flare". In theory, you know that you are looking for inflammatory cells and "flare”, which resembles a light beam being filtered through smoke.

"Cell and flare" on slit lamp

There is a fantastic educational video from www.RootAtlas.com demonstrating what "cell and flare" looks like and some tips to improve your slit lamp exam.

Go to video link.

Thanks to my fellow EM blogger Dr. Bearemy at "My Emergency Medicine Blog" for posting about this.