Holiday break: Dec 22-Jan 2

Happy a safe and wonderful holiday season. 

Will be back on January 3, 2011!

Humorous video: Trying to admit a patient

One of the downsides of practicing in the Emergency Department is trying to convince an admitting service that a patient should be admitted to their service. Here's a funny take on the problem.

Article review: Selected abstracts from 2010 CORD Academic Assembly (pt 2 of 3)

In the 2010 CORD-CDEM Supplement in Academic Emergency Medicine, 29 abstracts were selected from the CORD Academic Assembly. I reviewed the Abstracts #1-10 last week. Here's a quick look at Abstracts #11-19. Maybe there's something that you might be interested in pursuing or reading more about. Personally, I love reading about what educational studies are ongoing on out there.

‘‘Are They Who They Say They Are?’’ New Behavioral-Based Interview Style 
Robert E. Thaxton, Robert J. Kacpowicz, John Rayfield (Wilford Hall Medical Center, USUHS and San Antonio Military EM Residency)

In this 2-year retrospective review of 32 residents to an EM program, 3 residents required disciplinary action. These 3 residents scored only 2.93 (on a scale of 1-10 with 10 being the best) on a behavioral-based scoresheet, which was based on a bank of standardized interview questions on leadership, motivation, flexibility, interpersonal skills, and decision making. Scoresheets were completed by faculty interviewers when these residents interviewed at their program. In contrast, the other 29 residents scored an average of 8.19. The authors conclude that professional behavior may be quantified and predicted by this interview approach.

Resident Values: Are They Important?
Robert E. Thaxton, John Rayfield (Wilford Hall Medical Center, USUHS and San Antonio Military EM Residency)

This 3-year retrospective study attempted to correlate resident disciplinary action with their interview question "Why is Medicine as a career important to you?"This interview was conducted upon entering the residency program by an APD. Responses were classified as either internal/personal focus or external/others focus. Of the 11 residents (of 78) who received disciplinary action, 8 had an internal focus and 3 had an external focus. Interestingly of the 8 with an internal focus, the disciplinary action involved areas of professionalism. Of the 3 with an external focus, the disciplinary action involved areas of medical knowledge (2) and professionalism (1).

Physician Perceptions of the Effect of Implementing a Standardized Written Plus Verbal Patient Sign-Out Process in an Academic Emergency Department 
Jason D. Heiner, Jason M. Desadier, Benjamin P. Harrison (Madigan Army Medical Center)

This survey study using a convenience sample of 31 participants (21 EM residents and 10 EM staff) studied their opinions of a combined verbal AND written sign-out process (i.e. handoff) in the ED. After implementation of the new sign-out process, 81% felt that the sign-out process was somewhat better or much better and 61% felt that their comfort with the sign-out plan was somewhat better of much better.

‘‘I Want a Real Doctor’’: The Effects of Physicians in Training on Patient Satisfaction in the Pediatric Emergency Department
Brian W. Walsh, Alex Troncosco (Morristown (NJ) Memorial Hospital)

This multicenter, 5-year, retrospective study looking at Press Ganey surveys at 4 pediatric EDs evaluated patient satisfaction scores for when a physician in training (student/resident) was present and absent. Results from 1,373 ED visits revealed that doctor satisfaction was very slightly lower (87.9 vs 86.4, mean difference 1.5, 95% CI 1.3 to 1.7) with a physician-in-training. Oddly, the likelihood that the patient would return was higher (85.4 vs 84.4, mean difference -1.0, 95% CI -1.7 to -1.3) with a physician-in-training. In the end, although these differences are statistically significant, they are very slight, conflicting. Physicians-in-training probably do not tremendously affect patient satisfaction.

Does Subspecialty Training Affect Patient Satisfaction? 
Brian W. Walsh, Elizabeth Haines (Morristown (NJ) Memorial Hospital)

This multicenter, 5-year retrospective study looking at Press Ganey surveys at 4 pediatric EDs evaluated "overall satisfaction", "satisfaction with doctor" and "likelihood to return" scores for EM-trained vs Pediatric EM-trained physicians. There was no difference across all three outcome measures.

Social Networking Websites and Internet Media As Residency Recruitment Tools 
Bjorn K. Peterson, Eric J. Dahl, Cullen B. Hegarty (Regions Hospital, St. Paul, MN)

This abstract describes a program's educational innovation to harnass social media platforms to promote their residency program to potential applicants. Short video clips give viewers an overview of the program were posted on YouTube and Facebook.

Teaching Academy for Emergency Medicine Faculty 
Michael A. Bohrn, David C. Vega, Noelle A Rotondo, Rebecca I. Bluett (York PA Hospital)

This abstract describes an EM department's education innovation in faculty development. EM faculty teach other EM faculty about bedside/clinical teaching over four 2-hour small-group sessions. These sessions cover bedside teaching, feedback and evaluations, teaching portfolios, and sharing of individual teaching projects.

Advanced Competency in Electrocardiography (ACE) Program for Emergency Medicine Residents
Michael A. Bohrn, Rebecca I. Bluett (York PA Hospital)

This abstract describes a residency's educational innovation in creating a certificate program in Advanced Competency in Electrocardiography (ACE) for only the top-performing EM residents. The certificate program requires that residents complete additional monthly assignments and self-study readings about advanced concepts in ECG interpretation.

Faculty Evaluations of Emergency Medicine Residents Using an Audience Response System Michael J. Rest and Laura J. Bontempo (Yale University School of Medicine, New Haven CT)

Faculty members often evaluate residents in a non-anonymous forum amongst other faculty. One program changed its practice by collecting faculty evaluation scores at a monthly meeting by an audience-response system (ARS), which is typically used in lectures. This allows for anonymous scoring and a platform where everyone's "voice" counts. This survey-based study assessed 17 or 24 (71% survey response rate) faculty members who felt that an ARS system increased the accuracy of resident evaluations.

Paucis Verbis card: Subarachnoid hemorrhage high-risk characteristics

In Wednesday's post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada.

We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it's difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don't miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache.

In this 5-year multicenter study, the investigators identified clinical decision rules to help identify the higher-risk groups for a subarachnoid hemorrhage. They derived 3 models, based on recursive partitioning. Each has a negative predictive value of 100%.

Before thinking about seeing if your headache patient has any of these high-risk features, pay special attention to see if s/he would have met the inclusion and exclusion criteria of this study.

Inclusion criteria:

• Neurologically intact adults (age ≥ 16 years) with a non-traumatic headache peaking within an hour.

Exclusion criteria:

• History of ≥3 recurrent HA’s of same character/intensity
• Referred from another hospital with confirmed SAH
• Returned for reassessment of same HA which was already evaluated for SAH
• Papilledema
• New focal neurologic deficits
• Previous dx of cerebral aneurysm or SAH
• Previous dx of brain neoplasm
• Known hydrocephalus

Although none of the models are validated as of yet, the cumulative list of clinical characteristics from these 3 models may be able to help you understand who may be at higher risk:

• Age ≥ 40 years
• Witnessed loss of consciousness
• Neck pain or stiffness
• Onset of HA with exertion
• Arrival by ambulance
• Vomiting
• DBP ≥ 100 mmHg or SBP ≥ 160 mmHg

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Perry JJ, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010; 341:c5204. PMID: 21030443
Read article for free at BMJ Online.

Hot off the press: CORD is on Facebook!

Welcome to the Council of EM Residency Directors (CORD) to the social media world of Facebook!  By clicking on "Like", you can follow CORD's announcements about graduate medical education in EM and upcoming deadlines/events.

View the CORD Facebook Page.

Tricks of the Trade: Top 100 EM articles

In this educator-version of Tricks of the Trade, I wanted to let you know that the folks over at Denver Health (Dr. Jeff Druck) and the Carolinas EM programs (Dr. Dave Pearson) are updating their "Colorado Compendium of Top EM articles".

For those interested in keeping abreast of the landmark articles up to 2009, take a look at the list of Top 100 EM articles that they compiled. This publication is made available for FREE through the Western Journal of Medicine in the article entitled: "The Colorado Compendium: An Article-Based Literature Review Program"

Go directly to West JEM article.

Selecting "Supporting Material" in the left column will download the 104-page PDF to your desktop.

They review some classics including:

• "The rational clinical examination. Is this patient having a myocardial infarction?" in JAMA 1998.
• "The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease" in JAMA 2000.
• "Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis" in NEJM 2003.
• "The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma" in NEJM 2003.
• "Computed tomography of the head before lumbar puncture in adults with suspected meningitis" in NEJM 2001.

The Compendium editors are looking for suggestions on recent literature that you feel should also make the list. One publication that I find missing is:

• 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. 

Anyone other suggestions?

Evernote Site Memory feature

Thanks to my friends Jill and Rob, I learned about a cool feature that Evernote launched, which allows you to save web posts into Evernote form. I'm starting to realize that more and more of my colleagues are using Evernote for work and play. Read how I use Evernote for work.

Basically site developers choose an icon from the list above and then input the HTML code into their articles. When users want to clip the article, clicking on the icon automatically clips everything into a new folder in your Evernote account. With a little HTML coding knowledge, I can change the article title, notebook title, and add tags.

I'll be adding a "Remember" icon at the bottom of posts in case you want to clip anything (especially the Paucis Verbis cards).

Article review: Selected abstracts from 2010 CORD Academic Assembly

In the 2010 CORD-CDEM Supplement in Academic Emergency Medicine, 29 abstracts were selected from the CORD Academic Assembly. Here's a quick look at the first 10. Maybe there's something that you might be interested in pursuing or reading more about.

The Patient Experience: A Novel Educational Experience in the ACGME General Competencies

Catherine A. Marco, David F. Baehren, and Kristopher Brickman (University of Toledo, Toledo, OH)

In this retrospective survey study, 8 PGY-1 EM residents shadowed patients from triage to disposition and found positive and negative examples of the ACGME competencies - Professionalism, Systems Based Practice, Patient Care, and Interpersonal and Communication Skills.

Political Advocacy Project for Emergency Medicine Residency 

David C. Lee, Joseph LaMantia, Andrew E. Sama, and Theodore Sung (North Shore University Hospital)

The purpose of this curricular innovation was to enhance political awareness and action amongst emergency physicians. PGY-4 EM residents at the program were required to complete a political advocacy project where residents each studied a federal or local bill, summarized their findings to the EM program, and contacted their local political representative. 

Successfully Introducing Interns to Academic Medicine: A Curriculum for Participation in the Annual Society for Academic Medicine Meeting 

Jeffrey N. Love (Georgetown University/Washington Hospital Center)

This curricular innovation involved a structured experience for PGY-1 EM residents at the annual SAEM meeting, which included attending didactic sessions, select abstract presentations, and interest group meetings.  Upon their return, each resident then reported on 3 abstracts/papers at the departmental journal club.

The Effect of a Novel, Emergency Department Based Work-Study Program on Medical Students’ Perceived Skills and Clinical Competency 

M. Tyson Pillow, Shkelzen Hoxhaj, Angela Fisher, Donald Stader, and Theresa Tan (Baylor College of Medicine)

This retrospective survey study evaluated 1st year medical students who were provided the opportunity to participate in a work-study program where they learned how to perform phlebotomy, place peripheral IVs, and obtain ECGs in the ED. Eleven of the 53 respondents (21%) had participated in the work-study program. Compared to the non-participants, their comfort level on a 0-4 point scale were much better for phlebotomy (3.6 vs 0.2), IV placement (1.6 vs 0.1), and ECG acquisition (3.2 vs 0.6). 

Is Academic Productivity Amongst Emergency Physicians Affected by a Salary Incentive Plan?

Randy J. Hartman, Timothy C. Stallard, David L. Morgan, and Cindy F. Rush (Texas A&M University Health Sciences Center)

This retrospective observational study evaluated the consequence of an EM department's moving from an academic salary incentive plan (which rewarded scholarly activity, conference attendance, and completion of resident evaluations) to a clinical-based salary incentive plan (which rewarded clinical RVUs only). Results showed that the percentage of faculty submitting projects dropped by 62.5%, conference attendance decreased by 9.8%, and completed resident evaluations dropped by 24.7%.

EM-CROS: A Model for the Development of an Emergency Medicine Curriculum for Rotating Residents 

Tyler S. Jorgenson, Ian B. K. Martin, Kevin J. Biese, Cherri D. Hobgood (UNC-Chapel Hill School of Medicine)

This curricular innovation focuses on teaching off-service residents rotating in the ED. One article was selected in 7 core topics each-- chest pain, sepsis, altered mental status, shortness of breath, abdominal pain, headache, and cervical spine trauma. These articles and test questions were distributed to the residents for independent study. While on shift, the residents were encouraged to evaluate a variety of patient complaints, by having them each check off a card-based list of procedures and patient encounter objectives for the rotation period.

Medical Students’ Perceptions of an Emergency Medicine Clerkship: An Analysis of Self Assessment Surveys 

Jennifer A. Avegno, Heather Murphy-Lavoie, Lisa Moreno-Walton (Louisiana State University Health Sciences Center - New Orleans)

This 1-year survey study evaluated EM clerkship students' change in confidence level with patient management, resuscitations, oral presentations, procedural skills, and understanding of EM practice after completing an EM clerkship rotation. A secondary outcome measure was comparing these items between the 2- and 4-week clerkship groups. All of the students felt more comfortable with patient management and basic procedural skills after the EM clerkship. Students in the 2-week clerkship felt less confident in their formal presentation skills and most basic procedures (except ECG interpretation, splinting, and venipuncture) compared to those in the 4-week clerkship.

Reducing Unnecessary Administrative Time of Student Scheduling by Utilizing a Template System and Google Documents 

Jeffrey T. Van Dermark, Derek L. Kelly, and David deGive (UT Southwestern Medical Center at Dallas)

This curricular innovation empowered EM clerkship students by allowing them to select their own EM shift schedules based on a pre-templated schedule posted on Google Docs. Before the start of the rotation, students were allowed to decide amongst themselves who was assigned to each of the 10 evenly-weighted EM shift schedules. This significantly freed the administrative staff and clerkship director from burdensome administrative work to accomodate everyone's schedule requests.

Emergency Medicine Residents Exhibit Varied Learning Styles 

Nicole M. Deiorio and Donald E. Rosen (Oregon Health and Science University)

This survey-based study evaluated the learning styles of 30 EM residents based on the Kolb Learning Style Index. This self-assessment tool categorizes learners into Convergers, Divergers, Accomodators, and Assimilators. Amongst the 22 residents who responded,  59% were Convergers, 0% were Divergers, 23% were Accomodators, and 18% were Assimilators. With a variety of learning styles, the authors propose that the EM conferences and didactic curricula should be designed with this in mind.

Video Feedback to Students Can Be Easy and Inexpensive 

Nicole M. Deiorio and Ryan T. Palmer (Oregon Health and Science University)

This curricular innovation involves delivering feedback to medical students in a delayed fashion using video messaging. If real-time feedback is not possible, faculty can use a website (www.eyejot.com) to record and email their short video messages to the student for free. The authors hypothesize that subtle cues and nuances from the video format make the feedback more impactful than if done in text form.

Reference
Multiple authors. 2010 Council of Emergency Medicine Residency Directors (CORD) Selected Abstracts Acad Emerg Med. 2010. 17, Supplement: S1-S10. DOI: 10.1111/j.1553-2712.2010.00884.x

Paucis Verbis card: Cervical spine imaging

There is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice.

The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients.

                                  Sensitivity        Specificity
    NEXUS study            99.6%           12.6%
    CCR Study                 99.4%           45.1%

NEXUS
National Emergency X-radiography Utilization Study

A patient’s neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are met:

1. No posterior midline neck pain or tenderness
2. No focal neurological deficit
3. Normal level of alertness
4. No evidence of intoxication 
5. No clinically apparent, painful distracting injury*

* Defined as “a condition thought by the clinician to be producing pain sufficient to distract the patients from a second (neck) injury. Examples may include, but are not limited to the following:

1. Long bone fracture,
2. A visceral injury requiring surgical consultation,
3. A large laceration, degloving injury, or crush injury,
4. Large burns, or
5. Any other injury producing acute functional impairment

Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.”

Canadian C-spine Rules (CCR)

The basic approach in this flow-chart is to (1) make sure that the patient meets the same inclusion criteria as in the CCR study. Then (2) determine if there are high-risk findings. If so, go directly to imaging. (3) If there are no high-risk findings, check to see if the patient qualifies as a low-risk candidate where you might be able to clinically clear the c-spine without imaging. (4) If the patient is neither high or low risk, then the patient is moderate risk and requires imaging. Here's a flow chart that I made to help you remember:

(click to enlarge)

Note: Many emergency physicians go straight to CT imaging for patients with neck tenderness and moderate/high risk findings.

I personally rarely use the CCR algorithm because I can rarely remember all of the criteria. NEXUS is nice because of its simplicity. Where the CCR algorithm IS helpful is in clinical clearance of the low-risk patient with neck pain. I've cleared many patients who self-present with a whiplash mechanism (simple rear-end motor vehicle crash) and diffuse neck pain. By NEXUS criteria, you'd have to image them because they have neck tenderness. By CCR criteria, if they can actively rotate their neck 45 degrees left and right, they don't have a clinically significant c-spine injury. No imaging needed.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Keeping updated with iPhone medical apps

Thanks to a reader, Sheng-Wen, I came to learn about a website, which provides developments in the rapidly growing world of mobile apps in Medicine.

http://www.imedicalapps.com/

Here are recent postings:

• How the mobile phone and a UCLA researcher’s imagination are tackling epidemics around the world.
• Eponyms app offers a great free medical database reference tool for Android phones [Review]
• Heart Illustrated is a free well drawn cardiac anatomy app – potentially useful for patient education [iPhone review] 
• A milestone in electronic health record adoption: free, web-based Practice Fusion now is the largest commercial EHR
• In the future, your medical app may come from your hospital not from an app store
• iPhone Addiction Disorder (IAD) diagnosed by Psychiatrists in Taiwan
• “Prognosis: Your Diagnosis” app allows clinical case simulation on the iPhone for free [App Review] - 

It's worth checking out.

Trick of the Trade: Self-Reflection

This Trick of the Trade focuses on teaching learners in the ED.

After a shift, we often review the day's case with our learners. We sometimes ask them to self-reflect.

I often used Demian's 'Plus/Delta' approach and ask 'What did you like /what would you change?'

This approach works well mostly. But, when the answer is 'I don't think I would change anything', it is hard to target teaching and feedback to the learner's need.

Trick of the Trade: What case did you like the least?
Recently, I started asking this question, 'What case did you like the least?'

I like it since the learner now clarifies their learning need. This sets the stage for a meaningful exchange suited to the specific learner. This ties in with the coaching theme that was reviewed previously.

Sometimes the answer would not be what I expected at all. For example, a star internal medicine resident expressed hesitancy about suturing, and an excellent emergency medicine resident wanted more independence. Without this probing question, I might not have picked up on those needs.

What other ways do you coax learning needs?

Wound closure videos and VIPER page

New on the blog: 

Procedural teaching videos

In 2005, I started my VIPER project (Video Instruction of Procedures in the ER). I'll be uploading these videos. You will be able to find them under the VIPER Videos page. If you have other educational videos which you'd like to submit for this page, feel free to email me.

The first videos to be uploaded are on basic Wound Closure, which have been used for various medical student courses at UCSF and various other medical schools. There are 12 chapters.

• Chapter 1: Equipment (1:54 min)
• Chapter 2: Anesthesia (3:09 min)
• Chapter 3: Irrigation (1:11 min)
• Chapter 4: Starting the Procedure (2:30 min)
• Chapter 5: Simple Interrupted (3:45 min)
• Chapter 6: Horizontal Mattress (3:11 min)
• Chapter 7: Vertical Mattress (1:10 min)
• Chapter 8: Corner Suture (1:30 min)
• Chapter 9: Buried Suture (1:51 min)
• Chapter 10: Dermabond (1:56 min)
• Chapter 11: Steristrips (0:39 min)
• Chapter 12: Staples (0:47 min)

Article review: Consensus methodologies in qualitative research

What types of methodologies are used to develop a consensus statement? 

I'm in the midst of helping to write a consensus statement manuscript in education and ran into this great review article. It's from the British Medical Journal in 1995. 

Basically, there are 2 general types of methodologies:

• Delphi Process
• Nominal Group Technique 

Delphi Process
An example of a consensus topic might be: How will patient care be affected by the new ACGME Duty Hours rules? The Delphi process takes several rounds of discussions:

• Round 1: Opinions are expressed on a particular issue and categorized into headings
• Round 2: Participants rank their agreement with each statement in the summarized opinions.
• Round 3: Participants view the Round #2 rankings and comments and re-rank their agreement with the opinions.

The final results are analyzed for agreement. If there is no consensus, Round 3 is repeated. The Delphi Process allows a large number of experts to participate in a consensus statement because this entire process can be performed via email.

Nominal Group Technique
In contrast to the Delphi Process, the nominal group technique involves fewer experts (usually 9-12).  Furthermore, this approach requires face-to-face discussion, which adds a more personal element to the methodology.

• Step 1: Each participant contributes one idea to the facilitator, who records it on a flip chart/projector screen.
• Step 2: The comments are grouped into different categories.
• Step 3: Each participant privately ranks each idea.
• Step 4: The results are tabulated and discussed in a large-group setting.
• Step 5: Each participant privately re-ranks each idea.
• Step 6: The results are tabulated to determine consensus.

Reference
Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995, 311(7001), 376-80. Download the free PDF.

Paucis Verbis card: Dysphagia

Dyphagia is a disorder of swallowing. It actually occurs in up to 10% of adults older than 50 years old. How can you determine the most likely causes for dysphagia? The secret is to obtain a thorough history and using the algorithm below, which I find really helpful from a review article in American Family Physician.

How do you read the figure?

• Determine first if patient has oropharyngeal vs esophageal dysphagia. 
• Determine if mechanical (problem is solid foods only) vs neuromuscular (problem with liquids and solids)is more likely.

Tip:

• Medications can cause dysphagia from esophageal mucosal injury or reduced lower esophageal sphincter tone.
• CVA is most common cause of oropharyngeal dysphagia

Workup:

• Endoscopy
• Barium swallow
• Consider esophageal pH probe, manometry

(click image to zoom in)

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference 
Spieker MR. Evaluating dysphagia. American Family Physician, 2000, 61(12), 3639-48. Read the review article online.

Hot off the press: Medical Student Educator's Handbook

It's finally here! 

The second edition to the Medical Student Educator's Handbook is finished.

Here's the info from the CDEM website:

The first edition of this book, titled Medical Student Educator’s Handbook, edited by Drs. Douglas Ander, Wendy Coates, and David Manthey, was developed by the Society for Academic Emergency Medicine (SAEM) Undergraduate Medical Education Committee and Medical Student Educator’s Interest Group. In 2008, Clerkship Directors in Emergency Medicine (CDEM) was formed as an academy within SAEM. CDEM is now the national voice of emergency medicine clerkship directors and medical student educators.

This book represents the collaborative efforts of CDEM members to update the previous edition. The goal of this book is to assist EM faculty interested in medical student education in their efforts to develop a more successful emergency medicine clerkship based on highlighted best practices. This book is intended to offer the reader tools to deal with the challenges of running a successful EM clerkship, including addressing administrative and political considerations, promoting faculty, supporting faculty involvement, determining methods for evaluation, and developing novel teaching tools. We envision its use as a reference for up-to-date, practical information.

Oh, and did I mention that it's FREE!? It's a great reference for educators, chief residents, and anyone interested in academics. Congrats, Rob and Siamak (editors-in-chief).

Download the Medical Student Educator's Handbook

(2 MB)

Trick of the Trade: Laryngospasm notch maneuver

What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED?

Answer = 0.3%

A child with laryngospasm can be a scary thing to manage. There's no way to predict whether a child is going to get it.

You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don't work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first?

Trick of the Trade: Laryngospasm notch maneuver
This maneuver, mentioned in the anesthesia literature, is more based on a single physician's longitudinal experiences (Dr. Philip Larsen, Professor of Clinical Anesthesiology at UCLA). Anecdotally, many pediatricians and anesthetists use it. I haven't found any published studies on this maneuver though. Interestingly though, I've found it mentioned in 2 EM blogs by Life In The Fast Lane and Dr. Bearemy from earlier this year. Better late than never for me, I suppose.

Technique:
Firmly push the soft tissue just behind the earlobes of the patient's ears. Be sure not to go too inferiorly along the ramus of the mandible. You want to push at a point as superior as you can go in this notch. Push both sides firmly inward towards the skull base. Simultaneously, push anteriorly similar to a jaw-thrust maneuver. This should break the laryngospasm within 1-2 breaths.

It's unclear about the mechanism behind why this works. Here are some theories:

• You are just performing a jaw-thrust maneuver. 
• You are providing a deep painful stimuli, which causes the vocal cords to relax. 
• You are stimulating deep cranial nerves which happen to also stimulate the vagus nerve. 

Anyone have success with this maneuver in the pediatric patient? It would be a great case report publication. Nothing in the literature at this point. 

Read the original online commentary by Dr. Philip Larson in the Anesthesiology journal.