Trick of the Trade: Dix-Hallpike maneuver

The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV). 

• Place the gurney's head of the bed down flat. 
• Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney. 
• Rotate patient's head 45 degrees.
• Help the patient lie down backwards quickly.
• The patient's head should be hanging off of the gurney edge in about 20 degrees extension.
• Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV.

I find two things challenging in this maneuver. 

• The patient often does not like to be moved AT ALL while feeling nauseously vertiginous. This even includes trying to reposition the seated patient closer to the head of the bed. This requires them to look behind them to see what where they are going, which sets off more vertigo.
• In some of our ED rooms and hallways, the head of the gurney bed is often abutting a wall, a portable monitor, or some equipment. It takes a little fancy shuffling to make room for the Dix-Hallpike maneuver.

Trick of the Trade:

Place blankets under the shoulders for the Dix-Hallpike maneuver

The key is to maintain about 20-30 degrees of neck extension to align the posterior semicircular canals with the direction of gravity. Placing several blankets under the patients' shoulders can accomplish this same position without having to scoot the patient close to the gurney edge. I'm sure the patient would appreciate keeping their head movement to a minimum.

Poll: YOU be the residency director - Let's hear your thoughts!

We talk about ethics for treating patients. Are there also similarly thorny issues in medical education? Would love to hear what both learners and educators think about these scenarios.

Here is one for starters:

It is the social night out at a residency interview. A candidate got extremely drunk, vomited and passed out on the bar stool. Should that behavior be included in the assessment by the selection committee?

PLEASE EXPLAIN YOUR REASONING in the Comments link below. We'd love to hear your thoughts.


For those who answered YES, should we tell candidates explicitly that they will be watched during this social event?

Paucis Verbis: Approach to rashes

Doc, what's this itchy rash?

Answer: Contact dermatitis from poison ivy

We see a variety of rashes in the Emergency Department. The first step is to accurately describe the rash. Is this a macule or nodule? Is this a vesicle or bulla? The next step is to quickly "profile" the rash to see if it fits any classic pattern by patient age, rash distribution, or presence of hypotension. And finally, if you are still stumped, use an algorithm based on the rash type.

These figures are from March 2010's Emergency Medicine Magazine (it's free!). It's not meant to be a comprehensive article on rashes but it sure does take the guesswork out of 90% of the rashes you see.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Hemal Kanzaria for including this idea as a PV card. 

Trick of the Trade: Crossed straight leg raise test

A 35 year old man presents with low back pain which radiates down his right leg to the level of the knee. Is this sciatica?

Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is the sciatic nerve.

The straight leg raise (SLR) maneuver tests for such irritation. By passively elevating the patient's extended right leg, this maneuver stretches the sciatic nerve. If compressed or inflamed, this maneuver will reproduce pain in the sciatic nerve distribution. Note that isolated back pain with this maneuver does NOT mean a positive SLR test.

In a 2010 Cochrane review, the SLR test yielded a high sensitivity (92%) and low specificity (28%). This means that a negative SLR almost rules out a sciatic radiculopathy and disk herniation at the L4-L5 and L5-S1 level.

What about all those patients who have back pain and a little hamstring muscle vs sciatic nerve irritation with the SLR maneuver? Is there a more specific test?

Trick of the Trade: 
Crossed Straight Leg Raise maneuver  

For a patient with back pain radiating down their right leg, also perform the crossed SLR maneuver. If elevating their LEFT leg passively reproduces pain down his/her affected RIGHT leg, this is highly predictive of a sciatic radiculopathy and disk herniation. The crossed SLR maneuver essentially stretches the left L4-L5-S1 nerve root and thus tugs on the right L4-L5-S1 nerve root.

The 2010 Cochrane review shows that the crossed SLR has a low sensitivity (28%) but really high specificity (90%) for disk herniation.

Reference
van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, & Aertgeerts B. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane database of systematic reviews (Online). 2010 Feb 17;(2):CD007431. PMID: 20166095

Sharing Paucis Verbis cards using Evernote app

Hot off the press!

As of yesterday, the comprehensive note-taking/organizer software Evernote has made a significant upgrade. Your mobile app version can now view shared notebooks.

Previously, you could share notecards or files with others using the "Shared Notebook" option. A major limitation was that you could only view files in these folders from the web application of Evernote  -- not your desktop or your mobile device.


What does that mean now?
On your mobile device, such as your iPad or iPhone, you can now automatically get my Paucis Verbis  (PV) cards every week. You don't have to manually download them. In fact, you might get an early preview of a PV card, since I usually make then 1-2 days prior to posting them on the blog. I keep them all in a Shared Notebook on Evernote.

How to link to my PV Shared Notebook:
1. Go to the public link:
http://www.evernote.com/pub/michelleclin/paucisverbis

2. In the upper right corner, click on the "Link to my Account" icon. This should create a PV folder in your list of "Linked Notebooks". This will require you to sign-in to Evernote, if you have not already.

3. After you update your Evernote app, your mobile device will now list "Shared notebook" as a new folder in your list of Notebooks (see image above). All of my PV cards should appear in this folder now.

Let me know if this doesn't work for you.

Beware the night shifts!

Night shifts in the Emergency Department are not just shifts when it's dark outside. They are wrought with risk. Thanks to the folks over at RN Central for this eye-opening infographic.



Research and design by Nursing Schools Site

Paucis Verbis: An approach to persistent tachycardia

Tachycardia is a common clinical occurrence in the ED. Most of the time the etiology can be discerned through the history and physical exam, but sometimes it cannot. This is problematic especially when we are about to discharge a patient home but his/her heart rate is still 115 beat/min. We can't send this patient home yet. Do we then have to admit them for work-up of persistent tachycardia?

Attached is a list of common causes of tachycardia in the ED, as well as potential diagnostic and therapeutic considerations. Rather than a shot-gun approach, a limited and thoughtful method works best.

Can you think of other potential causes?

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

This useful PV card was made by one of our new star faculty members at San Francisco General Hospital, Dr. David Thompson. Thanks, David!



As you may have noticed, I will be starting to include a QR code on each PV card to this blog site, since people have been asking where these cards are from. Commonly QR codes are used to embed contact information or a website address. If you don't have a QR reader for your phone, you should get one. It's only going to be getting more popular.

Here's the iTunes link for a free iPhone QR reader, and below is a short demonstration of a QR code which directs the user to a specific website.

Trick of the Trade: Using a funnel for NG tubes

One of the indications for nasogastric (NG) tube placement is to instill fluids or medications. This may be saline or water for NG lavages or charcoal. You can manually push fluids into the NG tube via a 60 cc syringe, but this may take a long time for large volumes.




Trick of the Trade #1:
Pour fluids into an open-ended syringe

Pull out the plunger from a 60 cc syringe and attach the syringe to the NG tube port. Then pour in the fluids, using the syringe as a funnel. Be careful -- be sure that the patient doesn't feel like gagging or is very nauseous. Vomiting can produce a messy Vesuvius-like eruption!

Trick of the Trade #2:
Empty a 1 liter bag of IV fluids. Instill the fluid (in this case - charcoal) using a syringe. Snuggly attach the IV tubing to the NG tube port to infuse the charcoal. Tape may be needed to prevent the juncture from leaking.

Thanks to Dr. Sa'ad Lahri and Dr. Hennie Lategan (Cape Town, South Africa) for this IV bag-NG charcoal idea!

The future of the ALEM blog

It has been over 2 years now that my guest bloggers and I write blog posts 5 days a week. The process of writing, maintaining, and collaborating on ideas for the blog has completely changed my career. It has opened new doors, introduced me to new colleagues and friends worldwide, and clarified the direction of my career.

Now as I find myself involved with more projects, I need to re-structure my time (unless someone can find me an extra hour a day to work). It was a good run though. Honestly, I'm surprised that I maintained this pace for so long. The blog was meant to be my little experiment and foray into the Web 2.0 world to catalog my personal thoughts and learning.

So after much consideration, I will be moving from a Monday-Friday schedule to a Tues and Friday model. Whenever I encounter interesting resources, I will post them on an intermittent, unscheduled basis. This contradicts the teachings that one can only gain blog followers with a very regular schedule, but then that was never my goal. So here is the schedule, based on popularity trends that I have noticed:

• Tuesday:  Tricks of the Trade tips
• Friday: Paucis Verbis cards

I still welcome readers to contribute ideas, tricks, and Paucis Verbis cards. Often these get more internet traffic than my own posts!

Happy Friday the 12th

OK, I just made up a holiday. 

I totally ran out of time to make a new Paucis Verbis card today, because I'm at a big 3-day retreat on developing a new online software resource for EM. I'm the co-Editor in Chief of this online and mobile app tool. Looking to take over the world. I want to divert from traditional practice where authors are invited by colleagues, based on the fact that they are friends or the topic relates to their area of research. Instead I'm soliciting the virtual collective for interested authors!

If you are a faculty member and interested in being an author for a digital textbook chapter in the EM areas of Trauma or Psychiatry, please email me. I can provide more details.

TED Video: A lesson from spaghetti sauce on appreciating diversity

One size does not fit all.

This is the crux of Malcolm Gladwell's 18-minute talk. He gave this talk just before his book "Blink" went huge. He makes an eloquent argument for the nature of choice and happiness. There is no one perfect spaghetti sauce that fits everyone. There is no one perfect Pepsi which everyone likes.

If you translate this to medical education, why are we teaching our learners all the same way? There is no one-size-fits-all solution. Learning should be more individualized. Perhaps we can cluster students by learning style or personality types?

Trick of the Trade: Splinting the ear

Auricular hematoma

One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space?

Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D's) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the "ear sandwich". Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging because of the shape of the head.

I'm just not sure how much direct pressure to the hematoma is applied using this technique, because the xeroform and ribbon gauze are so soft.

Trick of the Trade:

Build an ear splint using plaster

1. Create a plaster roll to appropriately fit the patient's ear and soak it in water.

2. Wrap with just one layer of padding so that the plaster does not stick to the patient's ear.

3. Wedge the ear splint firmly in place and apply gauze behind the ear.

4. Apply several layers of gauze on top of the ear. Secure in place with a beanie hat (see prior Trick of the Trade).

EM-RAP Educator's Podcast: How to get promoted in academic EM

Dr. Amal Mattu gives a great 47-minute lecture on "How to Get Promoted in Academic Emergency Medicine". Catch the podcast from the talk in July's EM-RAP Educator's Edition. He pulls many of the lessons from his son's kindergarten teacher.

Getting promoted in academic EM can often be a challenge and a mysterious process. Why is it some are getting promoted faster than others? What can I do to make sure I'm on track for promotion?

It's all about hard work AND working smart.

Here are some tips for success:

1. Learn the rules of the game. It's about meeting deadlines and knowing what format your application for promotion should be in.

2. Keep a real-time, careful CV of your accomplishments in research, teaching, and service. If you don't, you may forget a lot.

3. Get involved with medical school committees (more valued than hospital committees).

4. Find teachers, coaches, and role models for yourself.

5. Get to love research and writing.

6. Not all publications are valued equally.

7. Find an academic niche or area of expertise.

8. Be a do-er and not a whiner.

9. Don't communicate with people when you are angry.

10. Think national and not just local. Get out and speak at outside institutions.

There are lots more little pearls. Take a listen!

Advice for the new EM interns, part II

As a followup to a previous post on "The 10 Commandments in Emergency Medicine", we would like to pay tribute to our pediatric friends. More than a decade after it was initially published, Timothy Givens (also from Vanderbilt but the pediatric side) published "The 10 commandments of pediatric Emergency Medicine". Although the original commandments still hold true, the pediatric commandments augment them nicely and are geared towards our littler patients.

1. Children are not small adults.

2. Ill and injured children regress.

3. The "patient" might be the one holding the child.

4. Kids are the real deal.

5. Laboratory tests and x-rays seldom beat a good history and physical examination.

6. Many hands make light work.

7. Check and double-check. Then, check again.

8. Children feel pain just like you do - treat it.

9. Close the loop.

10. Above all, you are the child's advocate.

Welcome to the new interns!

Reference

Givens T. The ten commandments of pediatric Emergency Medicine. J Emerg Med. 2004;27(2):193-4. DOI: 10.1016/j.jemermed.2004.05.002
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Paucis Verbis: Spinal epidural abscess

One of the most challenging diagnoses to make is that of a spinal epidural abscess (SEA), especially if you work in an Emergency Department which cares for many IV drug users and HIV patients. There's never before been a published diagnostic guideline or algorithm which helps you with risk-stratification.

In the Journal of Neurosurgical Spine, a diagnostic guideline was prospectively evaluated on a small population (n=31) as compared to historical controls (n=55). They found that an ESR test had a sensitivity of 100% if a patient had at least 1 risk factor for SEA. A CRP test was much less helpful.

Unfortunately, they didn't study the utilization rate of the MRI scanner with this guideline. Are they getting better results (fewer diagnostic delays and fewer cases of patients later in their clinical course) because they are just scanning more people?

Regardless, this algorithm may help you in shaping your diagnostic decision.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011;14(6): 765-70. PMID: 21417700
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Faculty hero: Dr. Jim Adams (part 2)

Continuing from the Part 1 (Aug 2, 2011 post), here is the rest of my conversation with Dr. Jim Adams:

What cool things are you working on right now?
The big projects that I am working on include:

• The second edition of the textbook for which I serve as Executive Editor. It will be published in 2012. 
• I am President of the Association of Academic Chairs of Emergency Medicine. There is so much happening nationally in emergency medicine and in healthcare in general. Health policy experts often rightfully criticize the US healthcare system for spending the most money without being the best in the world. The US is ranked somewhere around 32nd best. But there is consensus that the emergency care system in the US is indeed the best in the world. There is great training, skilled EM specialists, strong networks, and it is all fully accessible to anyone. We need to take pride in this as a specialty. We also need to be sure that it does not get broken. Nobody intends to, but there certainly can be unintended consequences given the rapid pace of change.

What advice do you have for junior faculty?

• My advice is to learn the good messages that were delivered to me by mentors and colleagues.
• We all appreciate that this is serious business, so there is no easy way to learn it. We just have to work hard and become good.
• We need to stay humble, because none of us are as good as we need to be or as good as we can be. We need to stay rested because the work is relentless.
• We need to make sure that we take care of ourselves. Working in an emergency department is a really hard job. We underestimate how tough it really is.
• And most importantly, if we put it all together, we do a super job for the patients.

What advice do you have for EM residents?
I tell all the residents that we selected them, because we know they are smart and now their job is to become comfortable being stupid. They need to be able to admit when they do not know, they need to become comfortable admitting their weakness because that is harder for them than being tough. Such healthy admission prevents arrogance, allows us to ask questions, permits us to continually learn. With that attitude, we and the patients are better, safer, happier. We are, paradoxically, can then be more confident.

__________________  •  __________________

What a really amazing time this is, with excellent colleagues in EM and in every other specialty. I am so pleased that emergency medicine, and other fields, are attracting such great people. It is up to us to keep the profession great so the talent keeps coming.


Thanks for sharing these eloquent words of wisdom, Jim. Words to live by. 

Trick of the Trade: Balloon animals in the ED

Back in July 2010, I wrote about using the Candleflame app to encourage pediatric patients to take deep breaths for a pulmonary exam. This app has also been useful in helping me roughly gauge the patient's peak flow.

Trick of the trade:

Balloonimals app

What kid doesn't love balloon animals? 

You can download the Balloonimals "Lite" app on your iPhone for free. Have the child blow forcefully at the mouthpiece of your iPhone. This will inflate a balloon. Shaking your iPhone will magically convert the balloon into a cute T-Rex dinosaur. Touching the screen will animate the 3D dinosaur. Touching the air pump icon will pop the balloon.

Balloonimals Lite app [iTunes app store]



For an extra $1.99, you can download the full version, which includes different balloon animals.



Thanks to Dr. Susan Brim (UCSF-SFGH EM resident) for the tip! Disclosure: I do not have any affiliations with the company.

Faculty hero: Dr. Jim Adams (part 1)

There are many leaders in Emergency Medicine but there are few who are true visionaries. Dr. Jim Adams (Chair at Northwestern's Department of EM) is one such visionary. He's given numerous lectures, providing sage advice to faculty, residents, and students. I've always thought it a shame these aren't more available to people. So I contacted Jim to learn more about him, his career path, and advice for young emergency physicians.

One thing that you are known for is your commitment to teaching professionalism and communication skills. How did that come about?


When I was  a resident in 1990 at the University of Pittsburgh, responding to the field on tough EMS calls to back up the medics, there were a lot of troubling cases. Patient who were really sick refused care. Patients at the end of life had paramedics attempt resuscitation, but not because it was warranted or desired, but because state law mandated it.

I worked with Paul Paris, then the Department Chair and also then President of the National Association of EMS Physicians (NAEMSP). I said that NAEMSP needed an ethics committee. Three months later, after checking with the NAEMSP Board, he said, "Ok, you are the chair." I was a senior resident.

My earliest academic work was to profile ethical dilemmas that occurred in the out of hospital setting. I also worked to ensure that each state and jurisdiction developed laws or guidelines to honor out of hospital DNR orders. My career in ethics was born. The ethics work morphed into professionalism, communication, and related areas that I work in to this day, more than 20 years later.

You mentor so many people around the country, including myself. What have you learned from your mentors?

Don't be lazy.
Work hard.
Be honest.
Do something good.

The residency at Pittsburgh taught me to go-- go to the field, move on the ethics problems, contribute energy to good things. It is a high energy place. Mentors, friends, colleagues in the United States Air Force taught the value of ultimate discipline. The military is remarkable. Those are people that I really would trust my life to. The Brigham and Women's Hospital colleagues and mentors taught the value of thinking more, being more rigorous, becoming deeper, understanding the value of true excellence. I have learned a huge amount from every setting and I am quite aware and grateful for that.


Stay tuned for Part 2 on Thursday... [post]

Article Review: Performing a database search

At the end of each Academic Medicine journal issue, there is a great "last page" one-page teaching point in medical education research. There's no earth-shattering news, but they are great reviews of key elements in education research.

The most recent issue reviews the process of performing an effective database search in medical education research. It was authored by my friend Lauren, who is a medical education librarian at Stanford and a co-author with me on an annual series "Critical Appraisal in Emergency Medicine Education Research".

Steps for an effective search methodology:

1. Choose a database: Did you know that there's more than just Medline?

• Google Scholar: Diverse disciplines; open access
• ERIC (Education Research Information Center): Focuses only on education literature; open access
• CINAHL (Cumulative Index to Nursing and Allied Health Literature): Nursing and allied health literature; subscription needed
• Scopus: Includes broad literature from scientific, technical, medical, and social sciences; subscription needed

2. Select search terms

• Use controlled vocabulary to perform a more complete search. Pubmed uses Medical Subject Headings (MeSH).
• Don't forget to use truncation. This allows you to avoid missing any slight variation in your search term. So for Pubmed, typing educat* captures educator, educators, education, educate, and educatify (if that word actually existed!) for instance. 

3. Use Boolean operators

• Use OR and AND connectors to broaden or narrow your searches, respectively.

4. Limit results

• Apply limits one at a time to your search to narrow your search pool in a stepwise fashion.
• Common limits applied: English language, date ranges

5. Explain the search process in the methodology section of any report: Your methodology should include all the following:

• Database(s) searched
• Search terms (indicate if controlled vocabular used)
• Boolean operators
• Limits applied
• Date of search

Reference
Maggio LA, Tannery NH, Kanter SL. AM Last Page: How to Perform an Effective Database Search. Academic medicine. 2011; 86(8) PMID: 21795907
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