Paucis Verbis card: Strep pharyngitis

Have you heard of the Modified Centor Score for strep pharyngitis? Interestingly, it has been validated in adults and children. The methodology builds on the traditional Centor Score by incorporating the patient's age, because this disease is more prevalent in kids than adults. In fact, you actually lose a scoring point if you are older than 44 years old.

There are 2 schools of thought about whether to use the Modified Centor Scoring system at all. One school (ACP, CDC, AAFP) recommends using the scoring system to guide testing and treatment. For patients with 4 or 5 points, don't even both testing. Just treat.

The other school of thought (AAP and IDSA) recommends testing everyone with ANY symptoms. They don't recommend using the Centor scores for making any clinical judgment, because of the insensitivity of any single sign/symptom.

Which school of thought do you subscribe to?

Personally, I use the Modified Centor Score to determine testing and treatment. It is more cost-effective, time-efficient, and supported by the literature. It eliminates both the very low and very high pre-test probability patients from rapid antigen testing. You either withhold or prescribe antibiotics, respectively.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

This AFP article is free for downloading at:

http://www.aafp.org/afp/2009/0301/p383.html

Reference
Choby BA (2009). Diagnosis and treatment of streptococcal pharyngitis. American family physician, 79 (5), 383-90 PMID: 19275067

Brain Slides: My new favorite blog

I just encountered a new blog called Brain Slides: Presentation Design for Educators, written by Nathan Cashion. This blog eloquently teaches how Powerpoint should and, more importantly, shouldn't be used.

Some presentation tips include:

1. Don't use bullet points, if you can avoid it.
2. Occasionally use a completely black slide to bring the attention of the room back to you.
3. Use more images and less text.
4. Burn your current Powerpoint lectures and start over with a new approach of less-is-more.

There are also some helpful examples of "Slide Makeovers". If you use Powerpoint for lectures, take a look at this site. It's worth it.

Trick of the Trade: Foley balloon be gone!

An urethral Foley catheter can sometimes become retained in the bladder, because of its balloon being unable to deflate. A malfunctioning inflation valve or obstructed channel along the length of the catheter is the cause.

How can you deflate the balloon so that the Foley catheter can be removed?

Option 1

Cut the Foley catheter's balloon port. This should remove the one-way valve device of the balloon port, and the balloon's contents should spontaneously drain. The Foley can then be easily removed.

Option 2

If option 1 fails, gently pass a thin guidewire into the inflation channel along the length of the Foley catheter. This should push away any foreign material (exudate, crystals) that have formed along the path. This should allow the balloon to drain spontaneously.

Option 3

Instill 10 mL of mineral oil into the inflation channel and wait 15 minutes. This should chemically dissolve the thin balloon. Repeat once if unsuccessful. This yields a 85-90% success rate of Foley removal.

I learned this from our urologist recently, who managed to pull out a retained catheter by using the guidewire trick.

Reference
Shapiro AJ, Soderdahl DW, Stack RS, & North JH Jr (2000). Managing the nondeflating urethral catheter. The Journal of the American Board of Family Practice / American Board of Family Practice, 13 (2), 116-9 PMID: 10764193

Need your help: Blog is joining the Facebook world

Last week, after reading more about blogs and their integration with Facebook, I thought I would give it a try. For those who check their Facebook accounts frequently, this may be an easier way to check-in on my blog posts. I initially built a Facebook Fan Page which imported this blog. It was supposed to then automatically import the updated daily content using a RSS feed. Unfortunately, this automatic feature doesn't work. So, I gave up on the idea and deleted the Page.

Just before abandoning all hope, I encountered a workaround third-party application called Networked Blogs. This application automatically imports your blog content in real-time. You can supposedly "follow" my blog from your personal Facebook page through this interfacing app.

You can access the link by clicking on the Facebook icon above or on the upper right of this screen. The only foreseeable downside is that you'll have to allow this third-party app access to your Facebook account. Click on the blue box "Follow". I would love to hear if this works or not.

Do my posts appear in your News Feed list or in an obscure section, such as the "Applications" page? Thanks for your help.

Article Review: Premature diagnostic closure

You are taking care of a patient, who frequently presents to the ED for polysubstance use. You are pretty sure his altered mental status is from polysubstance use again. He was found in his home next to drug paraphernalia. He intermittently becomes severely agitated, and so you give him sedatives. He has a low-grade fever, but you attribute that to his psychomotor agitation and likely stimulant use. Because he remains confused and lethargic after 8 hours, you admit him to an inpatient team to await further metabolism of his recreational drugs and your sedation medications.

The next day, you learn that had meningoencephalitis.

Cognitive biases are often the root cause for medical errors.

Specifically premature closure is the #1 cause of diagnostic errors. This Academic Medicine article attempts to study this concept of physician diagnostic flexibility (changing one's mind about the patient's diagnosis during the case presentation). Is it just a matter of teaching learners to avoid premature closure?

Methodology

• 256 primary care physicians viewed a simulated patient vignette video.
• Physicians were divided into MORE experienced (attended medical school during 1960-1987) and LESS experienced physicians (attended medical school during 1996-2001).
• The video is of a patient with signs and symptoms consistent with coronary heart disease (CHD). For the sake of authenticity, these patients concurrently exhibited some GI and stress-related symptoms.
• At the mid-point of the case, the physicians were surveyed about their initial impressions of the case.
• At the end of the case, the physicians were surveyed about their final diagnosis and disposition plans.

Results
The results actually were expectedly quite confusing. There are multifactorial causes for diagnostic flexibility and premature closure.

Case mid-point: More experienced physicians diagnosed CHD correctly (66%) compared to less experienced physicians (55%). This is no surprise. With more experience, you may make the correct diagnosis sooner.

Physicians who were the most likely to change their minds:

• Those with LESS experience. Specifically, if less experienced physicians selected a CHD diagnosis at the mid-point of the case, they were more likely to shift to a non-CHD diagnosis by the end of the case, compared to more experienced physicians. In this case, diagnostic flexibility was an undesired outcome. Interestingly, both less and more experienced physicians changed their diagnosis from non-CHD (mid-point) to a CHD final diagnosis with about equal frequency.
• Those who named a non-CHD diagnosis as their mid-point impression.
• Those who did not ask about patient's prior cardiac disease.
  

So what's the take-home point?

1. Clinical experience is invaluable.
2. Experience is likely more important than merely teaching learners to reason with a more analytical approach to avoid cognitive errors.

One way to teach pseudo-experience may be to present case conferences which illustrate real examples of premature closure and diagnostic flexibility.


References
Eva KW, Link CL, Lutfey KE, & McKinlay JB (2010). Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis. Academic medicine : journal of the Association of American Medical Colleges, 85 (7), 1112-7 PMID: 20592506

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Paucis Verbis card: Urine Toxicology Screen

In the Emergency Department, we often order urine toxicology screens for patients with altered mental status without an obvious cause. I find that patients are often rather forthcoming about their drug use, if they are alert enough to talk. In those cases, ordering a urine toxicology screen is unnecessary.

When you do order a tox screen, however, how do you interpret the information? While the results is a binary answer (positive vs negative), there are some nuances to interpretation. For instance, how long does a patient with urine toxicology remain positive for the drugs? Are there any medications that can cause false positives? See the helpful table below from a great review article in American Family Physician.

Check out what your laboratory screens for and, more importantly, what it does NOT screen for. Our lab, for example, does not screen for PCP but does screen for MDMA (ecstacy). That isn't a big deal, since patients who ingest PCP aren't too hard to detect clinically. They have crazy vertical nystagmus, and often there are at least 6 police officers trying to restrain the yelling patient.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Standridge JB, Adams SM, & Zotos AP (2010). Urine drug screening: a valuable office procedure. American family physician, 81 (5), 635-40 PMID: 20187600

Work in progress: KidsCareEverywhere website redesign

One of the great things in medical academia is that I get opportunities to participate in lots of amazing projects. I am currently a Member of the Board for a budding non-profit organization KidsCareEverywhere. Because of my interest in social media, web design, and branding, I am also the de facto webmaster.

Our prior website, designed by a professional graphic designer who donated his time, created a beautiful design layout which we used for a year. Unfortunately, it was a relatively static website -- primarily because I am a novice in manipulating HTML and CSS coding. It didn't reflect all of the great initiatives and projects that we have going on.

I just redesigned the KCE website using Google Sites to continually boost our visibility and legitimacy. This application allows novice web designers to create a professional looking website. There are multiple templates available to get you started. The key advantage in using this platform is that now I can give guest access to other members of our organization. They can now post in blog-like sections ("Hot off the press" and "Intern Blog") so that we have a dynamically changing and rich media content website.

www.KidsCareEverywhere.org

What I really love is that the Google Sites platform significantly improves inclusivity by allowing the least tech-saavy member to actively participate in web content development. You know who you are...

What next will Google come up with?! Needless to say, I'm a fan.

Trick of the Trade: A tongue blade is as mighty as an xray

Patients often present to the Emergency Department for mandibular blunt trauma. Usually these patients have soft tissue swelling at the point of impact. In mandibular body fractures, the fracture line often extends to the alevolar ridge. This may cause a gap between a pair of lower teeth (photo above).

In patients with jaw pain, mild swelling, and normal dentition, is there a way to avoid imaging these patients to rule-out a mandible fracture?

Trick of the Trade: Tongue Blade Test

A screening maneuver for mandibular fractures is the “tongue blade test.” Most patients with mandibular fractures will not be able to exert much bite force because of pain. The masseters are considered the strongest muscles in the body, and normal adults can usually easily bend and break a tongue blade, which is clenched between their teeth. Patients with mandible fractures are unable to perform this task without extreme discomfort, and difficulty performing this task should be considered at high risk for a mandible fracture.

Trick Variant

Traditionally, patients have been asked to hold the tongue depressor between their teeth and the practitioner tries to break it. Instead, let the patient try to break the tongue blad on their own, since it gives them more control and elicits less anxiety. In a prospective series of 110 patients with suspected mandible fracture, the test was found to be approximately 96% sensitive and 65% specific (1).

1. Alonso LL, Purcell TB. Accuracy of the tongue blade test in patients with suspected mandibular fracture. J Emerg Med. 1995 May-Jun;13(3):297-304.

This trick of the trade was published in ACEP News and first-authored by my innovative friend Dr. Matt Lewin. Tongue blade photos courtesy of Dr. Lewin.

Hot off the press: SAEM EM Interest Group Grants - due Jan 1, 2011

Every year, the Society for Academic Emergency Medicine (SAEM) awards 5-7 grants, each worth $500, to Emergency Medicine Interest Groups (EMIG). These grants used to be due every August but this academic year, they will be due Jan 1, 2011.

Take a look at the EMIG Grant website to see if your EMIG section is interested. Hey, it's free money to build interest and education in EM! Be creative.

The goals of the grant are:

• To promote growth of EM education at the medical student level
• To identify new educational methodologies advancing undergraduate education in emergency medicine
• To support educational endeavors of an EMIG

I believe a few years ago, UCSF's EMIG group received a grant to help defray costs of a cadaver-based procedures lab.

Article Review: Facebook, Professionalism, and Physicians

Facebook is worldwide.

The medical educator's dilemma about Facebook and professionalism seems universal. How do we teach medical students the importance of the digital footprints on publicly viewable websites? A landmark article, published by Dr. Chretein in JAMA in 2009, surveyed U.S. medical school deans on unprofessional behavior on Facebook. She found that 60% of medical schools documented incidences of unprofessional online postings.

In contrast, Medical Education just published a cross-sectional study whereby individual Facebook accounts were searched for publicly available content (rather than depend on recall by medical school deans). This study was conducted at the University of Otago in Wellington, New Zealand. The authors assessed recent medical school graduates and their use of Facebook (338 graduates from 2006 and 2007). They particularly focused on the following 3 pages:

• Info (personal information)
• Wall (comments to and by user)
• Photos

Outcome measures included:

• Facebook membership
• Exercising the privacy option
• Nature of publicly available content

Result

220 of 338 graduates (65%) had a Facebook account.

• 138 of 220 (63%) restricted their information to just Friends.
• 82 of 220 (37%) allowed their account to be publicly viewed.
• 38 (46%) showed photos of user drinking alcohol
• 35 (43%) revealed relationship status
• 30 (37%) revealed sexual orientation
• 13 (16%) revealed religious views
• 8 (10%) showed images of user intoxication

My comments about the study

Two things have changed since 2006-07 with Facebook.

1. Facebook's active user base has increased from 100 million (2008) to 400 million (2010) users.
2. Dr. Chretein's 2009 publication in JAMA has generated much publicity about Facebook, transparency, and professionalism in Medicine. Medical students and regulators may have changed their social media practices since then.

A followup study should be done to see if these findings are still true and whether more than 65% of medical students have a Facebook account.

But what IS professionalism in this Web 2.0 age that we live in?

Many experts state that the overarching principle of professionalism in Medicine is to "sustain the public's trust in the medical profession."

With it being so easy to sign up and share information on various social media platforms, how do physicians divide their personal and professional lives? How do you balance the right to free speech with the potential effect of making you and the medical profession look unprofessional The strengths of social media (transparency, immediacy, connectivity) are offset by potential pitfalls for medical practitioners.

One approach is to avoid posting any personal content on publicly viewable sites. Another is to tell your patients that, as a policy, you do not "friend" patients. Check out this great commentary in USA Today.

There is no perfect answer. Here's my personal approach-- Before publishing anything on social media platforms (Facebook, Twitter, this blog), I use this litmus test: "Is this something that I would be embarrassed to share with my idol, my patient, my boss, my future boss, and my grandparents?"

How do you define professionalism on social media?

Reference
Macdonald J, Sohn S, & Ellis P (2010). Privacy, professionalism and Facebook: a dilemma for young doctors. Medical education, 44 (8), 805-13 PMID: 20633220

Paucis Verbis card: Rapid Sequence Intubation

The key to success in performing procedures is preparation. This is especially true for endotracheal intubations in the Emergency Department where things are chaotic. Strategic planning and anticipation of obstacles during rapid sequence intubation (RSI) are key principles to avoiding complications.

Do you have any good tips or mnemonics?

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

[MS Word] [PDF]

See other Paucis Verbis cards.

How to teach procedures in the Emergency Department

As I was going through the free EM-RAP Educator's Edition podcasts, somehow missed the March 2010 podcast on how to teach procedures in the Emergency Department. In the 36-minute podcast, Dr. Mak Moayedi (Univ of Maryland) discusses a framework to teaching procedures. Check it out.

More specifically, Dr. Moayedi talks about how teaching procedures has moved beyond the antiquated "see one, do one, teach one" philosophy. Instead, we should follow principles based on accepted adult learning theories.

Ideal step-wise approach to teaching a procedure:

• Preparation (Prepare the learner, patient, and environment)
• Conceptualization (review indications and anatomy)
• Visualization (show procedure video in its entireity without interruption and repeated with your intermittent commentaries)
• Verbalization (have learner vocalize all the steps)
• Guided, supervised practice
• Give immediate and specific post-procedure feedback

Pitfalls:

• Avoid extraneous, distracting teaching points when teaching a procedure. This dilutes the key learning objectives.
• When teaching the novice learner a procedure, teach the standard, basic approach. Avoid teaching nuances in the technique, because this may also dilute the teaching message.

Trick of the Trade: OKN drum to test psychogenic coma

Occasionally, emergency physicians see patients who present because they are unresponsive despite normal vital signs and an otherwise normal exam. You detect no drugs or alcohol on board. You suspect a psychiatric or malingering etiology, but aren't sure. They seem non-responsive to voice and minimally responsive to very painful stimuli. Is this a case of psychogenic coma or true coma (with bilateral hemispheric dysfunction)?

What test can you do to reassure yourself that this may indeed be psychogenic coma?

Trick of the Trade:

Test for optokinetic nystagmus (OKN) using an OKN drum.

The optokinetic reflex allows us to follow objects in motion when the head remains stationary. Imagine as if you are a passenger in a car traveling on a highway, watching periodically-spaced telephone poles pass by. This can be reproduced by spinning an OKN "drum" directly in front of a patient. Spin the drum to create an alternating pattern of vertically-oriented black and white bars.

Normal OKN response

The eyes slowly pursue the moving bars in the same direction as the bars. Then quick saccade movement of the eyes in the opposite direction attempt to fixate on the next moving bar. A normal response requires a relatively normal visual acuity and intact fronto-parietal-occipital brain function. This nystagmus eye movement is called the optokinetic reflex. Check out this movie of a normal OKN response from the University of Utah's teaching files.

OKN Drum on the "Eye Handbook" iPhone app

Within the free iPhone app Eye Handbook, there's an OKN drum animation. You can speed up and slow down the pace at which the bars sweep through the screen.

For one particular "coma" patient, placing this screen in front of her revealed a normal optokinetic nystagmus response after "spinning the drum" leftward and rightward. I talked to her as if she were totally awake. I explained that we'd be starting an IV, getting labs, ordering a head CT if she weren't more awake soon. I told her to tell me when she was thirsty so that I could give her some water or juice. I asked her if she wanted to see a psychiatrist. No response. Thirty minutes later, she started talking and requested to talk to her psychiatrist.

Alternatively, a cold caloric test could have been performed to assess brain function.

Essential tool for academicians: Cordless presenter

In academic medicine, you inevitably will need to give presentations. This may include giving lectures on clinical topics, summarizing your research findings, or presenting your meeting agenda. Usually these are displayed using a laptop and a LCD projector. Depending on the room, you may or may not be provided a cordless presenter.

What is a cordless presenter?

This is a USB-enabled device which allows you advance your Powerpoint slides wirelessly.

Every few months or so, I find opportunities where presenters are surprised by the lack of an available cordless presenter. Such was the case at our annual department faculty meeting yesterday. Fortunately, I carry one in my laptop bag at all times. The attendees were surprised and wondered why I carry around such a device. A better question is - why DOESN'T everyone carry this around with their laptop?

I bought mine (Logitech Cordless 2.4 GHz Presenter) in 2007 for about $60. It now costs $69.99 from Office Depot. I don't have any financial ties to this product. I like it because it has a laser pointer, works on both Mac and PC with no set-up needed, and has a timer which vibrates at the 5-minute and 2-minute countdown mark. Here are the Amazon.com reviews. There are lots of newer models out there. I highly recommend getting one, especially if you give a lot of presentations on the go.

Article Review: What do EM learners want from teachers?

Evaluations of clinical faculty typically incorporate comments from rotating medical students and residents regarding their teaching ability. In the Emergency Department (ED), how do you balance your pressing clinical responsibilities with teaching?

There were 28 Canadian medical students and residents in their focus group interviews in this qualitative study. Learners were asked what qualities made a good EM teacher. Answers were transcribed and coded. There were 14 positive qualities identified. The top 5 were:

1. Has a positive teacher attitude
2. Takes time to teach
3. Uses teachable moments well
4. Tailors teaching to the learner
5. Gives appropriate feedback

What exactly does a "positive teacher attitude" mean? Learners wanted a teacher to be:

• Attentive to the learner
• Enthusiastic
• Approachable
• Communicates
• Takes initiative
• Honest
• Encouraging
• Open to questions
• Patient
• Flexible
• Sense of humor

What were qualities #6-14?

• Demonstrates useful ED skill
• Treats learner as a colleague
• Provides independence
• Sets expectations
• Teaches skills effectively
• Uses formal teaching techniques or sessions
• Possess formal training in education
• Uses teaching visual aids

My trick

At the beginning of the shift, I try to ask the learner what field that are in (if resident) or are intending to pursue (if student). I ask them if there's something that they want to learn more about while on the ED rotation. This already tells them that I'm invested in their education and will try to tailor teaching based on their interests. It's quick and simple.

Reference
Thurgur, L., Bandiera, G., Lee, S., & Tiberius, R. (2005). What Do Emergency Medicine Learners Want from Their Teachers? A Multicenter Focus Group Analysis. Acad Emerg Med, 12 (9), 856-861. DOI: 10.1197/j.aem.2005.04.022

Paucis Verbis card: Penetrating abdominal trauma

When I did my residency training in Emergency Medicine and in the first few years as an attending, we regularly performed diagnostic peritoneal lavages in patients with stab wounds injuries to the abdomen. Patients also routinely went to the operating room for exploration.

Now with the evolution of CT imaging technology and more clinical studies, there is now a role for a less invasive management approach. These are the Eastern Association for the Surgery of Trauma (EAST) guidelines.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Free wireless access at Starbucks

As of July 1, 2010, Starbucks shops have opened up wireless access for free. The trade off of this amazing convenience, of course, is digital security. Make sure that your laptop has turned off any file-sharing options and has turned on the firewall security option.

With good wireless access at work and home, I can use Starbucks wifi if I really need to check email on my iPhone while on the go. There seems to be Starbucks shops at every street corner these days!

It now makes me wonder how much I really need the 3G network for data access. I've heard rumors that AT&T will no longer be allowing unlimited data plan usage in the near future. They'll be charging money based on your pre-selected data plan.

Given more wifi accessibility now, it may be more cost-effective for me to purchase a simple cell phone and deactivate my iPhone so that it essentially becomes an wifi-capable iTouch with a camera. Hmm...

Happy surfing.

Trick of the Trade: Blowing out the candle

How do you teach pediatric patients, especially toddlers, how to cooperate with your pulmonary exam? How do you get them to take adequately deep breaths in and out?

Trick of the Trade: Blow out a candle

With your stethoscope positioned on the patient's back, ask the child to pretend like they are blowing out a birthday candle. Personally I have had variable success with this trick, because the child has to imagine a candle in front of them. Sometimes it works, but other times they just look at me like I'm crazy.

However, what if they had a virtual candle in front of them?

Trick of the Trade (high tech): Candleflame iPhone app

This free iPhone app displays a virtual candle burning for about 20 seconds. It is a slight hassle because a brief ad pops up at the beginning, which you have to manually select to skip over. It's worth the minor hassle, because one can blow out the candle if you sufficiently blow hard enough at the virtual candle. The sensor is the iPhone speaker piece at the bottom of the unit.

Since then, I have used this as a means to grossly assess an asthmatic child's peak flow ability if s/he can't coordinate using a peak-flow meter. You can adjust and increase the distance from the child to the iPhone to encourage maximal expiratory effort.

(Turn audio on in this video to hear me blowing out the candle.)

Work NOT in progress: ACEP Tricks of the Trade column

Since 2006, I have been the ACEP News columnist on "Tricks of the Trade in Emergency Medicine." Four years later, I've published and co-published 33 articles on various both low-tech and high-tech pearls.

It's official -- I'll be stepping down from the ACEP News columnist position and handing off the reins to someone with fresher ideas. Frankly, I'm running out of innovative ideas worth publishing about.

It was a tremendous opportunity for me to share some of my ideas with interested readers and I wanted to thank ACEP News, my editor at ACEP News (Terry Rudd) who fixed all my images and bad grammar, and Dr. Mary Jo Wagner (Synergy Medical Education Alliance) for trusting me to write the column.

Looking back, people have asked me how I came to be the Tricks of the Trade columnist. Like everything that I've done in academics, it's all about 50% luck and 50% hard work.

I had worked on writing a few chapters for a 2005 textbook that Mary Jo was involved in. I kept to deadlines and worked hard to make the chapters as well-written and updated as possible. Concurrently, I was building my lecturing skills by speaking at various AAEM and ACEP conferences. It was at one of these conferences at Mary Jo curbsided me and asked if I was interested in writing something for ACEP News. It would be a new column intended to help practicing emergency physicians to troubleshoot common dilemmas and obstacles in the ED, using innovative tools and approaches. The only instructions I got were -- Make it fun, make it practical, and include lots of photos.

It took me all of 2 seconds to overcome my insecurities and questions of "why me?" to jump at this awesome offer!

So if you too are looking for opportunities to get involved with various projects, I would say --

• Keep an open mind (and ear) about interesting projects.
• Always work hard. The quality of your work reflects directly on your skills, accountability, and reputation. Trust me -- it'll pay off in the long run.
• Don't burn bridges. You never know how your network of colleagues may help you down the road.
• Attend 1-2 national conferences annually. It's almost impossible to be present at these conferences and NOT get involved with meeting new people, listening to fascinating discussions, and joining collaborative endeavors.

Happy July 4th Weekend

Happy Fourth of July weekend!

Paucis Verbis card: Burns

In anticipation of one of the more injury-prone holidays, I thought it might be appropriate to review Burn Management in the Emergency Department. It's always good to review the rule of 9's, different classifications of burns, and indications for burn unit referral.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
GOMEZ, R., & CANCIO, L. (2007). Management of Burn Wounds in the Emergency Department Emergency Medicine Clinics of North America, 25 (1), 135-146 DOI: 10.1016/j.emc.2007.01.005