Academic Life in Emergency Medicine

Trick of the Trade: Difficult intubation -- making lemonade out of lemons

2012-01-31T03:00:00.000-08:00

(Image from http://xela145.deviantart.com)

In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn't adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.

Unfortunately, when you bag the patient, you realize that you are in the esophagus.

Trick of the Trade:
Leave the esophageal tube in.
Reattempt endotracheal intubation.

"When life gives you lemons, make lemonade."

If the endotracheal tube is in the esophagus, do NOT take it out! You have just created a conduit to remove further bleeding from the field. Take another look with Yankauer suction. Reattempt your intubation with a second tube. Do this as soon as you recognize an esophageal intubation to reduce the patient's risk for oxygen desaturation.

Note:

Be sure that the esophageal tube is turned away from the providers to avoid being splashed with blood.
Have an assistant suction the proximal port of the esophageal tube when blood starts pouring out of it.

Thanks to Dr. Marianne Haughey and Dr. Peter Gruber (Jacobi Medical Center) for sharing this tip. Quick thinking!

Paucis Verbis: Pediatric fever without a source (Birth-28 days)

2012-01-27T03:00:00.000-08:00

Pediatric patients commonly are brought to the Emergency Department for a fever without a source. Management of these patients depends on the patient's age. Today's PV card focuses on the youngest age group: Birth-to-28 days.

QUESTION to everyone:

Do you correct your age calculation for prematurity? Premature neonates are more at risk for SBI, but I've seen varying practices.

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

See other Paucis Verbis cards.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 29 days-3 months and 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

Trick of the Trade: Minimizing propofol injection pain

2012-01-24T03:00:00.000-08:00

"Ow, that burnnnnssss... ow! ow! ow! ... zzzzzz..."

As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it's too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds.

What can you do preemptively to minimize the pain of propofol injection?

Tricks of the Trade:

Place the IV in an antecubital vein (vs the hand).
Pretreat with IV opioids.
If the IV is in the hand, place a tourniquet proximally and pretreat with lidocaine.

The most effective thing you can do to minimize pain from propofol injection is to cannulate a vein in the antecubital fossa rather than in the hand. The relative risk reduction is 0.14. The larger, higher flow vein presumably reduces the pain. You should also pretreat the patient's pain with an IV opioid, such as fentanyl or morphine.

For the IV is in the hand, you should pre-treat with lidocaine. First, apply a tourniquet. Intravenously inject 0.5 mg/kg of lidocaine. For a 70 kg person, that's 35 mg. This equals 3.5 mL of 1% lidocaine. Release the tourniquet after 30-120 seconds, and inject the propofol. The number-needed-to-treat to prevent pain in one person, who would have had pain had they received placebo, is 1.6!

Thanks to Dr. Andy Neill (of Emergency Medicine Ireland blog fame) for the tip from the Life in the Fast Lane's Research and Reviews series.

Reference
Jalota L, et al. Perioperative Clinical Research Core. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ. 2011 Mar 15;342:d1110. PMID: 21406529.
Free PDF

Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg. 2000 Apr;90(4):963-9. PMID: 10735808.

Paucis Verbis: Antibiotics and open fractures

2012-01-20T03:00:00.000-08:00

Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED.

Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides?

Pearl: Once you have significant soft tissue injury, you are automatically have a Type III open fracture and should add an aminoglycoside.

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

See other Paucis Verbis cards.

Reference:

Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011 Mar;70(3):751-4. .

Trick of the Trade: Dental Avulsion/Subluxation

2012-01-17T03:00:00.001-08:00

It’s a Friday evening shift in the “minor area” of your EDand a young woman who had imbibed a little too much alcohol comes in with an avulsionof her first left upper incisor after falling and striking her face against theground. She’s crying because of theevent but is otherwise unscathed. Atthis point it’s time to take care of the avulsion. What to do? (see PV Card on ED Treatment of Dental Trauma)

Trick of the Trade:

Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique

Although originally described for dental avulsions, I havealso used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.

Lightly rinse tooth with saline solution.
Rinse socket with 20-40 mL of saline solution and thenpat dry with a surgical sponge.
Gently reimplant tooth into a satisfactoryanatomic position.
Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to themesial and distal edges of the tooth, thereby adhering it to the adjacent teeth. In this case of a left central incisor avulsion, "mesial" means right edge and "distal" means left edge in dental speak.
Use the pliable metal nasal bridge from an N95 respirator mask as a splint. Cut it to the appropriate size. Be sure to round the edges to avoid injury.
Secure the replanted tooth by applying 2-OCA to the inner aspect of thesplint and buccal surface of the target and one/both adjacent teeth.
Hold the splint under pressure for about 1 minute.
Confirm stability.

In addition, remember to startthe patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible.

Warnings:

Children: Avulsedprimary teeth should not be replanted. Also ensure they will not be at aspirationrisk.
Warn the patient that if they feel that the dental splint is loosening, simplyremove it.

Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.

Below are other images where we have successfully used this technique in our ED.

Reference

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375–7.

Paucis Verbis card: Interpretation of intraosseous blood

2012-01-13T03:00:00.000-08:00

There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Here's another one!

Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab?

In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample was drawn (4 mL). Then a second IO sample was drawn (4 mL), which is equivalent to a sample with the first 6 mL discarded.

Interesting, not all IO labs correlated with IV labs. The good news is that a few critical ones do show correlation: creatitine, glucose, and hematocrit.

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

See other Paucis Verbis cards.

Thanks to Dr. Michael McGonigal at Trauma Professional's Blog for posting about this.

Reference
Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010 Sep;134(9):1253-60. Pubmed
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Students/residents: Free 1-yr subscription to PEMSoft

2012-01-11T03:00:00.000-08:00

A January 2012 special!

It is still the season of giving… for medical students and residents.

The Editors-in-Chief of PEMSoft (Pediatric Emergency Medicine Software) want to share a one-year free subscription to a dynamic online pediatric EM reference. PEMSoft brings the medical library to the bedside! It is a point-of-care clinical support tool and knowledge system that is indispensable if you care for sick neonates or young adults. PEMSoft is also a superb educational resource--with over 3000 images and videos, as well as multiple interactive modules to refine diagnosis and treatment, and a sophisticated search engine to find topics instantly and to generate differential diagnosis.

PEMSoft has had a total makeover in 2012, with more than 8 special modules added to the updated vast, core knowledge base that now includes over 2000 topics. This new interface is especially suited for use on tablets and mobile devices at the bedside and on rounds. Previous reviews of the software have declared it "a new publication that completely resets the standards in its field" (Ped Emerg Care, 23(8); 2007). Test it out the new version for yourself! See our informational website at www.pemsoft.com for more details and testimonials from your colleagues.

I recently delivered donated versions of PEMSoft and trained tons of grateful physicians in Vietnam, on behalf of KidsCareEverywhere. A personal subscription of the online software currently currently costs $95/yr. In full disclosure, I am one of their section editors. I manage the multimedia Procedures section. If you listen closely, you'll hear my voiceover in several of the videos.

Visit our informational website: www.pemsoft.com
Enter the software itself: www.pemsoft.net
"Like" us on Facebook: http://alturl.com/kwpsz

How do you get this amazing 1-year free subscription? Fill out the form below, and I'll personally email you your username and password.

The deal expires Jan 31, 2012.

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Trick of the Trade: A removable guidewire

2012-01-10T03:00:00.000-08:00

An essential skill of any innovative troubleshooter in the Emergency Department is the ability to recognize when one piece of equipment may be used elsewhere. For instance, what's your go-to approach when looking for a spare guidewire? Let's say you are trying to salvage an ultrasound-guided basilic vein IV catheterization.

Here's where I go for guidewires:

Central line kits
Pneumothorax pigtail kits
Seldinger-based cricothyrotomy kits

Trick of the Trade:
Seldinger-based Arrow arterial lines

Thanks to Dr. Kennedy Hall (UCSF-SFGH EM resident), he recently discovered that the Seldinger-based arterial lines, made by Arrow, have removable guidewires! If you look closely along the length of the transparent guidewire sheath, there is a narrow slit which allows you to remove the guidewire. The added bonus is that there is a black plastic handle at one end of the guidewire which can protect against losing the guidewire into a catheter.

Whoa, it's like magic.

Neither Dr. Hall or I have any financial disclosures with the Arrow company.

Blog Incubator Experiment: Be the next big thing in blogging

2012-01-07T15:39:00.000-08:00

There are many health and technology incubators out there, which help to build start-up companies into thriving and profitable organizations.

Why can't we do this for those who are thinking about starting a blog? In 2009 when I was thinking about starting the blog, I had lots of support and encouragement. I slowly grew my readership by word-of-mouth and things really got going when the folks over at Life in the Fast Lane, Poison Review, EMCrit, and so many more graciously pointed their readers toward my site.

So for those of you interested in joining the Web 2.0 world and shifting your role as a "consumer" to "producer", I wanted to open up a competition: The Blog Incubator Experiment. I am soliciting applications for a person or team to write a 3-part series on Academic Life in Emergency Medicine.

You get an automatic readership with at least 300 hits per day.
You get a taste of whether you want to start up your own blog.
You see in the inner workings of a blog.

Eligibility:

You can not currently have a blog in the area that you are writing about.
You can be a medical student, resident, attending physician, physician assistant, nurse practitioner, nurse, or prehospital personnel in any specialty.

How to apply:

Email me (Michelle.Lin@emergency.ucsf.edu) your thoughts and vision for the 3-part series. Be as detailed as possible, and be creative!
You can submit more than 1 idea for the series.
The topic(s) for the series should be relevant to those practicing Emergency Medicine, and/or interested in education.
If selected, I would like to receive your 3 blog posts by March 1, 2012.

Deadline: January 31, 2012 at 5 pm (EST).

Notification of winner: February 7, 2012

Paucis Verbis: Serotonin syndrome

2012-01-06T03:00:00.000-08:00

What exactly IS serotonin syndrome?

It's caused by the excess of serotonin and presents classically as:

Altered mental status
Autonomic instability
Neuromuscular hyperactivity

Fortunately, there's a nice algorithm (Hunter's decision rule) which helps you decide whether it is serotonin syndrome or not. I also include a table, which I adapted from the New England Journal of Medicine review article on Serotonin Syndrome, which helps you to differentiate it from its mimickers, such as anticholinergic syndrome, neuroleptic malignant syndrome, and malignant hyperthermia.

(click to zoom in)

A video to remind you what clonus looks like:

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

See other Paucis Verbis cards.

Thanks to Dr. Steve MacDade (Univ of Florida, Jacksonville EM resident) for the idea!

Reference

Ables AZ, Nagubilli R. Prevention, recognition, and management of serotonin syndrome. Am Fam Physician. 2010 May 1;81(9):1139-42. Free AFP text.

Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20. .

Trick of the Trade: Hip dislocation Part II

2012-01-03T03:00:00.000-08:00

As a followup to the blog on the Captain Morgan technique for hip dislocations, I'd like to throw out another similar technique that also does NOT involve climbing up on the gurney.

The Whistler technique was developed in the ski town of Whistler, B.C., where the majority of their hip dislocations resulted from either a skiing or snowboarding accident. The technique applies the same principles as the Captain Morgan technique but uses the provider's forearm instead of their knee in the popliteal fossa.

The patient lies supine on the gurney.
Unaffected leg is flexed with an assistant stabilizing the leg. The assistant can also help stabilize the pelvis.
Provider's forearm is placed under the affected leg in the popliteal fossa then grasps the knee of the unaffected leg.
Provider's other hand grasps the lower leg of the affected leg, usually around the ankle.
The dislocated hip should be flexed to 90 degrees.
The provider's forearm is the fulcrum and the affected lower leg is the lever.
When pulling down on the lower leg, it flexes the knee thus pulling traction along the femur.
You can also add some internal/external rotation to facilitate the reduction.

Is it the definitive hip dislocation reduction technique? No...but something else to add to your bag of tricks when the usual doesn't work.

I've used the Whistler technique multiple times with success. The few times it hasn't worked, I've converted to the Captain Morgan technique. No more gymnastics on the gurney!!!

Has anyone else tried it?

Reference
Walden PD, Hamer JR. Whistler technique used to reduce traumatic hip dislocation of the hip in the emergency department setting. J Emerg Med.1999 May-June;17(3):441-4. Pubmed

Seasons greetings and happy new year!

2011-12-23T03:00:00.000-08:00

We will be on a brief hiatus to count our blessings, reflect back on the year, and revel in good cheer. Happy holidays!

See you in 2012!

Trick of the Trade: Tie-over dressing for scalp lacerations

2011-12-20T03:00:00.000-08:00

Scalp lacerations are apparently a hot topic these days. This is the third post now on how to apply a bandage to a scalp laceration.

Trick of the Trade:
Tie-over dressing technique

After suturing a laceration in place, leave the suture tails 6-8 cm long.
Roll up a piece of gauze.
Place the gauze roll on top of the sutured laceration.
Secure the gauze using the long tails of the sutures.
After 1-2 days, the patient should cut the tied-over knots to remove the gauze. This allows the wound to be inspected and cleaned.

For step-by-step photos, check out Dr. Gemma Morabito et al's Medicinadurgenza website post.

I have a question though:
I suture scalp lacerations only if the patient is balding or bald in the area. How would I bandage if you use staples instead of sutures for the scalp? I imagine my options:

Beanie hat approach
Hair braid dressing
Place 2-3 sutures to help close the laceration (interspersed amongst the staples) just to do a tie-over dressing
Don't bandage. Just cover up the staples with the overlying hair.

Thanks to Dr. Gemma Morabito (Rome, Italy) and Vincenzo Peloponneso (nurse in Cuneo, Italy) for the idea and images!

Reference
Ginzburg A, Mutalik S. Another method of tie-over dressing for surgical wounds of hair-bearing areas. Dermatol Surg. 1999 Nov; 25(11):893.

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Paucis Verbis: ACLS 2010 cardiac arrest flowchart

2011-12-16T03:00:00.000-08:00

(click for larger images)

In a earlier summary of the 2010 ACLS guidelines, Dr. Demian Szyld succinctly highlighted changes from previous guidelines.

There are 2 flowcharts (above) that the AHA provides. They are conceptually complete, but I had a hard time implementing the steps in real-time.

So, I created my own. Thanks to Dan, who commented in my chat box that I should make an ACLS card.

Tips:

2 minutes of continuous, uninterrupted CPR is key before rechecking the rhythm.
Think about giving epinephrine every OTHER time you check the rhythm. This puts it at roughly a q4 minute dosing (recommended q3-5 minutes).
Don't delay CPR when you recognize a cardiac arrest. That means do this first, and then work on giving oxygen, placing the patient on various monitors, setting up the defibrillator, and establishing IV/IO access. Hence, the C-A-B mnemonic (Circulation before Airway)
Chest compressions should be "hard and fast" -- Depth of at least 2 inches and ≥ 100 compressions with a target pCO2 on the end-tidal capnography of ≥10 mm Hg.
Use your mobile phone's timer to help alert you every time when 2 minutes is up.

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

See other Paucis Verbis cards.

References

Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-67. Review. Erratum in: Circulation. 2011 Feb 15;123(6):e236. Pubmed
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New kid on the block: ED Trauma Critical Care (EDTCC)

2011-12-14T03:00:00.000-08:00

Welcome the newest EM blog to the block: ED Trauma Critical Care. It's helmed by Dr. Amit Maini (St. Vincent's Hospital in Melbourne, Australia) and focuses on keeping us all up to date with the latest and greatest in trauma, resuscitation, and critical care.

Topics thus far:

IO vs IV access during out of hospital cardiac arrest, an RCT
Increased chest compression fraction on ROSC in nonVF cardiac arrest
Beware the pain in the neck...
Sedation in traumatic brain injury
Slightly funnier than placebo
Severe pneumonia and ARDS

Keep a lookout for many more great summaries and tips.

Trick of the Trade: Captain Morgan technique for hip dislocation

2011-12-13T03:00:00.001-08:00

Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient's bed.

Trick of the Trade:
Captain Morgan technique

You can apply 3 forces of axial traction to the femur.

Position the patient: 90 degrees of hip and knee flexion
Step one foot up onto the gurney Captain-Morgan style (flamboyant cape optional).
Position your knee behind the patient's knee.
Ideally your foot should be resting on a hard surface like a backboard to allow your foot to push off of it.
Place one hand (A) under the patient's knee and the other (B) over the patient's ankle.
Use Hand A to lift up on the patient's femur.
Plantar-flex your ankle so that your propped knee can lift up on the patient's femur.
Very gently use Hand B to leverage-down on against the patient's tibia/fibula.

TIPS FOR SUCCESS
Pearls straight from "Captain" Hendey (Dr. Greg Hendey wrote the article):

Make sure to put the patient on a backboard and attach a strap over the pelvis to stabilize it to the board--this works far better than having some tech trying to lie across the patient, and it's better than tying a sheet around the gurney and the patient. It also provides a firm place to put your foot.
Make sure to tuck your knee tightly under the patient's knee so that when you lift up on your tiptoes, all the force is transmitted into lifting the patient's hip. If your leg is much shorter than your patient's leg, you may need to put a book under your foot to get your knee tucked under theirs.
Once you're lifting, keep a steady sustained force, just like any large joint reduction--no sudden jerky movements. Once you feel it start to move, don't stop--sometimes people stop lifting too soon when they feel movement, but before the reduction has occurred.
If it's not moving, try rocking back and forth, and twisting the leg (internal and external rotation at the hip) while you're lifting.

Video 1:
The provider does not use Hand A to lift up, although it seemed that he kind of wanted to. Note that he was stepping on the hard bed under the soft gurney mattress.

Video 2:
The provider shows you how you really need Hand A to help you to lift.

NPR interview with the article's author and my friend, Dr. Greg Hendey (UCSF-Fresno).

Thanks to Dr. Graham Walker for letting us know about this great pearl from his new Gmergency! Tumbler site.

Reference
Hendey GW, Avila A. The captain morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011 Dec;58(6):536-40. Pubmed
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New SAEM Annual Meeting website

2011-12-12T03:00:00.000-08:00

SAEM has created a nice Annual Meeting webpage for the first time. It's a one-stop shopping site for information and abstract submission. Check it out!

http://am2012.saem.org/

Kudos to Jason at SAEM for doing such a great job with this.

Paucis Verbis: Feedback card

2011-12-09T03:00:00.000-08:00

Today's Paucis Verbis card is a little different. This card focuses on helping you give talking points when giving feedback to a learner on shift. This could be a medical student or resident.

Dr. David Thompson (UCSF-San Francisco General Hospital) sent this great card to me and I thought it was too useful NOT to share. It's handy on shift, which ultimately is the purpose of these Paucis Verbis cards. These are useful especially for senior residents, who are supervising medical students and junior residents.

There have been several blog posts on giving effective feedback in the ED:

Video: How to give effective feedback
Article review: Attending and resident satisfaction with feedback (prospective observational study)
Article review: Failing at feedback in medical education (JAMA article)
Article review: Teaching when time is limited
Podcast: EMRAP Educator's Edition on feedback
Plus-Delta technique for debriefing and feedback

This card can be used in many ways. For instance:

Print these cards and fill it out at the end of the shift. Give to the learner.
Pick 1-2 questions from the list below as launching points for your feedback discussion. You don't have to overwhelm the learner by answering everyone item below. Sometimes less is more to be effective.

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

See other Paucis Verbis cards.

Video: Social Media in Medicine - What is it and why?

2011-12-08T03:00:00.000-08:00

From LifeInTheFastLane.com's illustrious Dr. Mike Cadogan. These were the slides from his Social Media in Medicine talk at the recent USC Essentials Conference. It's time more physicians get involved and join the conversations that are taking place on social media. Join now.

Hey look! I can say I've finally made it when I get a mention from Mike in his slides!

Trick of the Trade: Bandaging the scalp laceration

2011-12-05T03:00:00.001-08:00

Scalp lacerations are one of the most common injuries which present to the Emergency Department. Applying a dry bandage over the staples or sutures can be a challenge because the tape just has nothing to adhere to.

We reviewed the use of tubular cotton gauze to create a beanie hat, but what should you do if you can't find any tubular gauze? Ever since I wrote about the beanie hat trick, people in the ED have been using the tubular gauze more and we're always out of stock whenever I look for it!

Trick of the Trade:
Use hair to create a "hair braid dressing"

This was actually published in the Neurosurgery literature in 2004, but I just heard of it from Dr. Gemma Morabito (Rome, Italy) of Medicinadurgenza website fame just this last month!

1. Apply gauze over wound by lifting overlying hair.

2. Criss-cross hair over gauze.

3. Using string or rubber bands, tie both hair braids to the hair underneath to securely "sandwich" the gauze.

4. Secure the two hair braids to the gauze with tape.

References

Yanaka K, Nose T. Braid dressing for hair-bearing scalp wound. Neurocrit Care. 2004;1(2):217-8. Pubmed
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Paucis Verbis: Acute vestibular syndrome and HINTS exam

2011-12-02T15:21:00.000-08:00

What is your diagnostic approach to the acutely vertiginous patient?

The bottom-line question is:
Is the cause peripheral or central in etiology?

In this great 2011 systematic review article in CMAJ on Acute Vestibular Syndrome (AVS), the authors review how (un)predictive elements of the history and physical exam are. By definition of AVS, symptoms must be continuous for at least 24 hours and have no focal neurologic deficits.

Frighteningly, the authors report many of the signs and symptoms (type of dizziness, hearing loss, patterns of nystagmus, Hallpike-Dix) are not as predictive as we classically are taught!

The take home point is to learn and incorporate the 3-part HINTS exam into your diagnostic approach (see bottom box on card). It is reported to be as good as a diffusion-weighted MRI for diagnosing a posterior stroke. The steps are:

Do the horizontal head impulse test. (Normal = central cause)
Check for directionally-alternating nystagmus movement on left and right gaze.
Do the alternate cover test.

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

See other Paucis Verbis cards.

The following is a hepful 10-minute video showing normal and abnormal HINT findings:

Head impulse testing
Nystagmus testing
Testing of skew

From Dr. Scott Weingart's video supplement to his EMCrit podcast on posterior strokes.

Thanks to Dr. Brian Resler (UCSF-SFGH EM resident) for giving me the heads up about this at Followup Conference!

Reference
Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14;183(9):E571-92. Pubmed
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Trick of the Trade: Securing a peripheral IV on sweaty skin

2011-11-29T03:00:00.000-08:00

Patients can become extremely diaphoretic with high fevers or if under the influence of PCP or a stimulant. Slippery, sweaty skin can pose a problem when securing peripheral IV's. Adhesive tapes that are typically designed for securing these IV's often slip off... immediately followed by the IV falling out.

How can you secure the IV ... without using staples and sutures?

Trick of the Trade:
Wrap non-cloth tape circumferentially around the arm.

Wrap the arm with a circumferential band of non-cloth tape which just covers the IV hub.
Slide a narrow strip under the IV hub and crisscross (Chevron-shape) over the hub.
Secure this strip to the initial tape band layer (and not the sweaty skin).
Place a third tape circumferentially around the arm just distal to and covering the IV hub and tubing.

Note: Be careful about wrapping anything circumferentially around an extremity. Routinely check the extremity to avoid creating an iatrogenic tourniquet.

Thanks to Tricia and the night-shift nursing team, who are always sharing great practical pearls.

Happy Turkey Week!

2011-11-22T03:00:00.000-08:00

In the holiday spirit of gluttony and giving thanks, we at Academic Life in Emergency Medicine are taking the whole week off to indulge in great food with great company.

Crowdsourcing all of your burning questions about EM

2011-11-21T03:00:00.000-08:00

Have you noticed that on "Who Wants To Be A Millionaire", asking the audience as a lifeline almost always results in the right answer (over 90% of the time)?

Dr. David Thorisson (Lund University, Scandinavia) recently approached me with a novel idea of doing the same for Emergency Medicine questions. These questions are currently posted to a public Google Docs document, which allows anyone to post and answer questions.

Google Docs link:
http://bit.ly/sWx7if

Some questions already posted include:

Can you share your tips for distinguishing between paroxysmal SVT & atrial fibrillation (when the rate is regular)?
What are the contraindications to low-dose ketamine (0.1-0.5 mg/kg) for sedation or agitation?
What is an accepted rate of miss for 1) ACS 2) PE 3) SA 4) Aortic dissection 5) C-spine fractures (requiring and not requiring treatment)?

Read about how David got started with this intriguing and innovative new project on his blog site Priceless Electrical Activity. Feel free to post more questions or take a stab at answering a question.

Paucis Verbis: The aVR lead on EKG

2011-11-18T03:00:00.000-08:00

What lead is the most overlooked on the EKG?

aVR

Lead aVR can provide some unique insight into 5 different conditions:

Acute MI
Pericarditis
Tricyclic antidepressant (TCA) and TCA-like overdose
AVRT in narrow complex tachycardias
Differentiating VT from SVT with aberrancy in wide complex tachycardias by using the Vereckei criteria (possibly better than Brugada criteria)

It turns out that aVR provides a lot of great information!

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

See other Paucis Verbis cards.

See also:

EM-RAP episode on ST elevation in aVR, featuring Amal Mattu nuggets of wisdom
LifeInTheFastLane blog post on ST elevation in aVR

References

Kireyev D, Arkhipov MV, Zador ST, Paris JA, Boden WE. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol. 2010 Apr;15(2):175-80. .
Riera AR, Ferreira C, Ferreira Filho C, Dubner S, Barbosa Barros R, Femenía F, Baranchuk A. Clinical value of lead aVR. Ann Noninvasive Electrocardiol. 2011 Jul;16(3):295-302. .
Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008 Jan;5(1):89-98. .
Williamson K, Mattu A, Plautz CU, Binder A, Brady WJ. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006 Nov;24(7):864-74. .

Calling all med students: SAEM Ambassador opportunity

2011-11-16T03:00:00.000-08:00

Are you a medical student interested in EM? Want to get your registration costs waived at a national meeting? Want to come say hi to me? Here is an announcement from the SAEM website (deadline Feb 1, 2012):

_____________________

SAEM is looking for 15 energetic, self-starting, responsible, and enthusiastic medical students to work with the SAEM Program Committee at the Annual Meeting in Chicago, May 9-12, 2012. The Program Committee is responsible for the planning, coordination, and execution of SAEM’s Annual Meeting. It is comprised of nearly 40 faculty members selected by the President of SAEM from Emergency Medicine programs all over the country.

Benefits for medical student committee members:

Waiver of your registration fee to the SAEM Annual Meeting*
A member of the Program Committee will be assigned to you to serve in an advisory capacity for future EM pursuits
Learn much more about the current research and educational activities taking place in the field of Emergency Medicine
Have the opportunity to form relationships with faculty members from EM programs around the country.
A personal letter from the Committee Chair will be sent to your Dean of Student Affairs, acknowledging your contributions to the Program Committee.

Requirements and expectations of medical student committee members:

Arrive the late evening of May 8th and stay through 3pm on May 12th.*
Attend daily Program Committee meetings
Seeing to assigned tasks and responsibilities, which include, but are not limited to: Approximately 6 hours of responsibilities per day, soliciting reviews, assisting in AV needs, facilitating workshops, being responsive and flexible to the needs of the Program Committee

Interested medical students should submit their name and contact information to the SAEM office by emailing Michelle Iniguez at miniguez@saem.org. Please write “Medical Student Ambassadors” in the subject line and attach a very short statement of interest (<150 words) as well as an updated electronic copy of your CV. Deadline is February 1, 2012. Recipients will be notified by February 10, 2012.

* Travel and hotel will be the responsibility of the individual student; however. SAEM will provide the emails of other selected students to facilitate consolidating lodging expenses.

PDF of the announcement

Trick of the trade: Foley catheter for DUB

2011-11-15T03:00:00.000-08:00

Your next patient has heavy dysfunctional uterine bleeding (DUB). She is tachycardic and pre-syncopal.

While you establish an IV, resuscitate her, and wait for the gynaecology team to arrive, is there any trick you can use to stem the bleeding?

Trick of the trade:
Foley catheter insertion into the uterus for DUB

The obstetricians sometimes use a Bakri balloon (Bakri postpartum balloon, Cook Medical) for postpartum bleeding. This balloon will take 250-500 cc of fluid. In the ED, a regular Foley catheter can be used.

Step 1:
Regular speculum exam. Remove clots.

Step 2:
Feed Foley catheter through the os by curved or straight forceps held close to the os.

Step 3:
When the catheter is in a few centimetres through the os (endometrial cavity is usually 6 - 8 cm deep), inflate the Foley balloon with 30-80 cc of water.

The balloon will hopefully tamponade the endometrium that it contacts and prevent further blood loss.

Illustration by Simon Yiu

Thanks to Dr. Jamie Kroft for this great tip!

Reference Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(6):748–757.

Video: Dr. Eric Mazur on peer teaching

2011-11-14T03:00:00.000-08:00

Dr. Eric Mazur is a Harvard Professor of Physics and Applied Physics who talks about his "confessions of a converted lecturer". He focuses on the power of peer teaching and the ineffectiveness of the traditional lecture format in a classroom.

This talk is 72 minutes long. Take some time to listen and learn. Dr. Mazur is such an engaging talk that I couldn't stop watching. Maybe it's because he looks a little like the comedian Steve Carell.

“My lecturing was ineffective, despite the high evaluations.”

“The traditional approach to teaching reduces education to a transfer of information.”

"The plural of ANECDOTE is not DATA."
-- Dr. Lee Shulman (ex-President of The Carnegie Foundation)

Paucis Verbis: Methotrexate for ectopic pregnancy

2011-11-11T03:00:00.000-08:00

Ectopic pregnancies account for as many as 18% of patients who present with first-trimester bleeding or abdominal pain in the Emergency Department. This Paucis Verbis card summarizes the 2008 American College of Obstetricians and Gynecologists (ACOG) guidelines on the use of methotrexate (MTX) for ectopic pregnancies. Not all ectopic pregnancies require operative management.

What are the indications and contraindications to MTX?

When should they follow up with their obstetrician?
Answer: In 4 days for a repeat b-HCG and possible second dose of MTX

Note that one of the eligibility criteria is that the patient must have an "unruptured ectopic pregnancy". Many would consider that any ultrasonographic evidence of free fluid may be a sign of an early rupture. It is left up to clinician judgment in how "unruptured" is interpreted.

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

See other Paucis Verbis cards.

Reference
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008 Jun;111(6):1479-85.
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Trick of the Trade: Ultrasound-guided injection for shoulder dislocation

2011-11-08T03:00:00.001-08:00

Who loves relocating shoulder dislocations as much as I do?

I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?

Trick of the trade:
Ultrasound guided shoulder injection

I found a great video on this technique, which is essentially a hematoma block in the joint. This screencasted talk is by Dr. Mike Stone (Highland Hospital) as part of his 2011 ACEP Scientific Assembly lecture on nerve blocks. Coincidentally, I ran into Mike at this week's UCSF Topics in Emergency Medicine course where he gave a talk on the use of ultrasound for the hypotensive patient. When I mentioned that I was going to highlight his shoulder injection trick on this blog, he whipped out his laptop and gave me the 6 minute portion of his ACEP talk. Wow, that was really nice of him.

To view his entire video on nerve blocks, check out the video here.

Things I learned about injecting the shoulder:
1. Use a spinal needle. A traditional needle often will not reach the glenohumeral joint.
2. You almost always get a flash of blood (hemarthrosis) when you are in the joint.

Also check out Dr. Stone's great ultrasound website called Point of Care:
http://pointofcare.blogspot.com/

I'm a fan.

Article review: Evaluating your written evaluation of a learner

2011-11-07T03:00:00.000-08:00

As a new faculty, one of the first challenges that I encountered was completing evaluation forms for medical students and residents. In our department, a Daily Evaluation Card (DEC) is to be completed at the end of every shift for each learner. These DEC’s are then collated by the program directors to yield a summative final rotation evaluation.

What I wondered was: how can I best use these DEC's to help learners progress as medical professionals and at the same time provide critical information for the PD’s?

Fortunately, I stumbled upon a 2008 Medical Education paper called “Assessing the quality of supervisors' completed clinical evaluation reports” by Dr. Nancy Dudek (University of Ottawa). This article was what I was looking for. Although this article was intended to evaluate the quality of the summative evaluation, the principles remain applicable to the DEC's.

The article is summarized below:

End-of-rotation evaluations usually consist of a checklist/rating scale and written comments. These forms have questionable reliability and validity.
End-of-rotation evaluations remain a valuable resource when trying to assess what a trainees "actually do" versus what they "can do" (eg. on an exam).
The study attempted to determine the features of a high-quality evaluation and to develop an instrument to assess its quality.

Methodology:

Using brainstorming and a modified Delphi consensus technique, a focus group developed a Completed Clinical Evaluation Report Rating (CCERR) form. This form was then tested nationally and revised to yield a tool which evaluated 9-items each on a 5-point scale. This CCERR tool was found to be a reliable and valid means to differentiate superior from average from poor end-of-rotation evaluations.

The 9-item CCERR checklist:

How would your own Daily Evaluation Card evaluations fare?

Use a 5-point scale (1 = not at all, 3 = acceptable, 5 = exemplary).

Checklist/ numeric ratings show sufficient variability to allow identification of relative strengths and weaknesses of the trainee.
Comments are balanced providing both strengths and areas for improvement.
The trainee’s response to feedback and/or remediation during the rotation is described in the comments.
Comments justify the ratings provided.
Clearly explained examples of strengths using specific descriptions (not generalizations) are provided in the comments.
Clearly explained examples of weaknesses using specific descriptions (not generalizations) are provided in the comments.
Concrete recommendations for the trainee to attain a higher level of performance are provided.
Comments are provided in a supportive manner.
Overall, this end-of-rotation evaluation provides enough detail for an independent reviewer to clearly understand the trainee’s performance on the rotation.

Reference

Dudek NL, Marks MB, Wood TJ, Lee AC. Assessing the quality of supervisors' completed clinical evaluation reports. Med Educ. 2008 Aug;42(8):816-22.

Paucis Verbis: Acetaminophen toxicity

2011-11-04T03:00:00.000-07:00

Did you know that the American Association of Poison Control Centers reports that 10% of poison center calls are related to acetaminophen ingestions? That's a lot. This Paucis Verbis card reviews the basics of acetaminophen toxicity. I included the Rumack Matthew nomogram to help you plot out the patient's risk for hepatotoxicity.

In the Emergency Department, we often screen for acetaminophen toxicity for patients who may have ingested substances as a suicide attempt. We check the serum acetaminophen level 4 hours post-ingestion. Occasionally, we are surprised by a toxic level because in the first 24 hours, because symptoms are can be mild and nonspecific (abdominal pain, nausea, lethargy).

I have a "Rule of 150":

The toxic ingestion dose of acetaminophen is 150 mg/kg.
The serum acetaminophen level when N-acetylcysteine treatment should be started is 150 mcg/mL (see Rumack Matthew nomogram)
The starting IV dose of N-acetylcysteine is 150 mg/kg over 15 minutes.

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

See other Paucis Verbis cards.

References
Larson AM. Acetaminophen hepatotoxicity. Clin Liver Dis. 2007 Aug;11(3):525-48, vi. .

Trick of the trade: Nebulized naloxone

2011-11-01T03:00:00.001-07:00

Overdoses of long-acting opiates, such as oxycodone and methadone, are challenging to manage, especially if these patients are chronically on opiates.

On the one hand, you want to reverse some of the sedative effectives with naloxone so that they aren't near-apneic and hypoxic. You also want to be able to take a history from them. On the other hand, you don't want to abruptly withdraw them with naloxone such that they become violent and agitated. It is a fine balancing act.

Long-acting opiates present a separate challenging because naloxone wears off fairly quickly in 30-45 minutes. These patients may require repeat dosings and/or a naloxone IV drip.

Trick of the Trade:
Nebulized naloxone

The beauty of naloxone is that it can be administered through a variety of routes which includes IV, IM, and intranasal. Reported in 2003 in the Journal of EM, the nebulized route is also effective.

Advantages:

Nebulized naloxone does not require an IV, which is often difficult to establish in IV drug users.
Instead of administering multiple doses of naloxone for long-acting opiates, nebulized naloxone can provide a steady, low maintenance dose similar to an IV drip but without needing an IV.
Nebulized naloxone is a self-titrating medication because when the patient awakens, s/he often will pull off the mask.

A good starting regimen is 1-2 mg naloxone in a total volume of 3-5 mL. You may need to add normal saline to reach the target volume. I recently used 1 mg naloxone in 3 mL with great success. The patient was able to give a brief history and remained non-agitated. For longer-term naloxone treatment, you will need to refill the nebulizer canister intermittently or request a large-volume nebulizer canister.

Note: If you need to reverse opiates more quickly, you might consider giving an intranasal dose of naloxone first, followed by a maintenance dose using the nebulizer.

Thanks to Dr. Ethan Cowane (Jacobi Medical Center) for this tip!

Reference

Mycyk MB, Szyszko AL, Aks SE. Nebulized naloxone gently and effectively reverses methadone intoxication. J Emerg Med. 2003 Feb;24(2):185-7.

Paucis Verbis: Influenza - To treat or not to treat?

2011-10-28T03:00:00.000-07:00

It's coming.

Influenza season is almost upon us.

Influenza season typically peaks in the United States during the Jan-Feb months and can start as early as October. You can read about the 2011-12 seasonal flu data on the CDC website.

Should you give a patient with influenza an antiviral agent or just provide supportive therapy?

This Paucis Verbis card summaries the CDC's Advisory Committee on Immunization Practices (ACIP) recommendations for this upcoming 2011-12 influenza season. I also let patients with uncomplicated influenza who are going to be managed as outpatients know that a 5-day course of osteltamivir or zanamivir will cost them about $50-80. Often that sways them towards declining a prescription and "toughing out" an extra day of the flu.

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

See other Paucis Verbis cards.

Reference
Centers for Disease Control and Prevention. Infectious disease. Antiviral agents for the treatment and chemoprophylaxis of influenza. Ann Emerg Med. 2011 Sep;58(3):299-303; discussion 303-4.
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G-Advising: Using Google Hangout to advise medical students

2011-10-26T03:00:00.000-07:00

Get an advisor.

Don't try to climb the mountain on your own.

This is key especially during medical school as you navigate through the mounds of reading, paperwork, options, and pitfalls. If you are interested in Emergency Medicine (EM) as a career, that means getting one or several great EM advisors. Don't rely on non-EM faculty to give you any insight into EM. Inevitably, I have found that they give incomplete or slightly skewed perspectives about the pros and cons of EM.

What if you don't have an established EM residency program or established EM faculty at your school?

Be proactive in finding an EM advisor. Sometimes that means looking outside of your school. That's what a medical student at the Philadelphia College of Osteopathic Medicine, soon-to-be Dr. Rick Pescatore did. We conducted a Google Hangout with the EM Interest Group where I got to field insightful questions about EM. I was at home and the students were in a classroom. Another student in the library actually linked into our Hangout partway through. The Hangout allows for up to 10 link-ins. The video and audio worked seemlessly!

Check out Rick's account of this cool approach to advising on his blog LittleWhiteCoats.

For those looking for e-Advisors in EM, I'm working with a team, lead by Dr. Megan Fix (Utah) and Dr. Rob Cooney (Conemaugh Health Systems), who are almost ready to launch the massive program in 1-2 months. Keep a lookout for it. There will be a list of available faculty, their academic affiliation, and their interests. You can select whomever you want.

This is just my first (of hopefully many) adventures in G-Advising using Google. Here is a video on Google Hangouts.

Trick of the Trade: Nasal cannula oxygenation during endotracheal intubation

2011-10-25T03:00:00.000-07:00

Image from EP Monthly

You are managing a 300-pound patient with a long history of severe COPD, who now requires intubation because of a pneumonia and COPD exacerbation. You anticipate that the patient may be a difficult airway intubation and may desaturate quickly during laryngoscopy. While you are setting up to orotracheally intubate this patient, you preoxygenate this patient as best as you can with a non-rebreather mask.

What can you do to prolong the patient's time-to-desaturation so that you aren't as rushed to place the endotracheal tube?
Trick of the Trade:
Administer high flow (≥ 5L) oxygen by nasal cannula during the face-mask preoxygenation and intubation.

A 2010 publication in the Journal of Clinical Anesthesia conducted a prospective randomized study looking at nasal cannula oxygen administration during endotracheal intubation. They found that such oxygen administration resulted in a much longer period before the patient desaturated to SpO2 < 95% (about 5 minutes WITH nasal cannula and 3.5 minutes WITHOUT it).

In a 2009 EP Monthly article, Dr. Richard Levitan (airway guru) advocates for high-flow nasal cannula administration (15L) during the intubation. Logistically, he recommends placing a nasal cannula under the face mask so that both are delivering oxygen while you are setting up for the intubation. For the intubation, the face mask is removed but the nasal cannula remains to continue delivering oxygen. In fact, Dr. Levitan recommends this for all patients (not just obese patients as in the above publication).

But wait, the patient is apneic, how would nasal cannula oxygen administration help?
Interestingly, the alveoli are constantly consuming about 250 ml of oxygen per minute. In the setting of apnea, it is theorized that the dropping partial pressure of oxygen in the alveoli creates a pressure gradient such that there is a "mass movement" of gas from the trachea and pharynx into the alveoli.

Thanks to Dr. Kit Tainter of EM Guidelines fame for the tip! Great to meet you in person finally at ACEP.

Reference
Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010 May;22(3):164-8.
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Paucis Verbis: Ventilator settings for obstructive lung disease

2011-10-21T01:03:00.000-07:00

Following up with last week's Paucis Verbis card on Ventilator Settings for Acute Lung Injury and ARDS, here is the card on Ventilator Settings for Obstructive Lung Disease. This is for patients who present with acute asthma or COPD exacerbation who require endotracheal intubation.

What initial ventilator settings should you

set for these patients?

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

See other Paucis Verbis cards.

Thanks to Dr. Jenny Wilson for the card and Dr. Scott Weingart for the original stellar podcast from which this card was derived.

2011 ACEP Scientific Assembly - A live Twitter feed by EMRA

2011-10-17T03:00:00.000-07:00

The 2011 American College of Emergency Physician (ACEP) Scientific Assembly is well under way in San Francisco. There is incredibly amazing weather this week. Catch a compiled live feed of the various Twitter accounts which mention the Scientific Assembly. If you are tweeting, be sure to use the #SA11 hashtag (a.k.a. bookmark). Thanks to Dr. Steven Horng from EMRA for organizing this.

http://www.emra.org/emra_involved.aspx?id=43594

Learn about who is tweeting from the meeting!

Paucis Verbis: Ventilator settings for acute lung injury and ARDS

2011-10-14T03:00:00.000-07:00

A patient presents with severe multilobar pneumonia and refractory hypoxia requiring endotracheal intubation. The respiratory therapist connects your patient to the ventilator.

"What settings would you like your patient on?"

(In reality, the respiratory therapist already has placed your patient on the appropriate initial ventilator settings already, but let's think this through ourselves.)

Back in 2010, Dr. Scott Weingart of EMCrit fame, posted a great podcast on "Dominating the Vent". It's such a fantastic distillation of the practical aspect of ventilator setting management of all intubated patients except those with an acute asthma or COPD exacerbation, Dr. Jenny Wilson and I thought this would be a great Paucis Verbis card to have in your peripheral brain.

Note: The tidal volume should be calculated based on Predicted Body Weight (PBW), which is based on patient gender and height. The calculation is at the bottom of the card. Using a patient's actual weight might yield a tidal volume that is way too high. The initial vent settings in the example box are for a patient with a PBW of 70 kg. That's basically a 5'9" man or 5'11" woman.

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

See other Paucis Verbis cards.

Thanks to Dr. Jenny Wilson for the idea and writing this card, and Dr. Scott Weingart for a great podcast as always.

Reference
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000 May 4;342(18):1301-8. Pubmed
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Remembering Dr. Robert Buckman

2011-10-13T03:00:00.000-07:00

For those who trained in Canada (especially Toronto), the name of Dr. Robert Buckman always brought a chuckle.

He filled his lectures with his signature British wit and humour. Yet, the message was always loud and clear. Being an oncologist, he had great insight in communication with patients.

He was the first to teach us medical students about communication and professionalism: Kindness, empathy, delivering bad news, what to say when you don't know what to say. A decade later, out of the countless hours of lectures, his stood out.

Truly a big loss to the medical educators community.

Dr. Buckman's website

References
Buckman R. Communications and emotions. BMJ. 2002 Sep 28;325(7366):672. BMJ website

Buckman R. Words that make a difference: enhancing the "how" in "how we say it". Support Cancer Ther. 2006 Jan 1;3(2):127. Free PDF

Buckman R, Tulsky JA, Rodin G. Empathic responses in clinical practice: intuition or tuition? CMAJ. 2011 Mar 22;183(5):569-71. Pubmed

Trick of the trade: Quieting the shaky EKG tracing

2011-10-11T03:00:00.000-07:00

A patient with Parkinson's disease presents with chest pain to your ED. Her tremors prevent you from getting a good quality EKG because of the movement artifact.

How can you eliminate this artifact? (No cheating with rocuronium.)

Trick of the Trade
Have the patient sit on his/her hands.

Although I haven't tried this myself, this trick apparently works for people with upper extremity tremors and movement disorders. Has anyone used this trick? It's been referenced in: Burdick E350 Operating Manual. Milton, Wis: Siemens Burdick, Inc; 1990.

Thanks to Brooke, RN for this tip, and Alex for being a hand-sitting model!

Paucis Verbis: Neutropenic fever in cancer patients

2011-10-07T03:00:00.001-07:00

A 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are:

Temperature 39 C
BP 160/80
HR 60
RR 14
Oxygen saturation 99% on room air

His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC.

Is this patient "high" or "low" risk per the Multinational Association for Supportive Care in Cancer (MASCC)?
Does this person require inpatient admission?
What antibiotics would you start on this patient?

Answers:

The patient's MASCC score is 5 (mild symptoms) + 5 (no hypotension) + 4 (no COPD) + 4 (solid tumor) + 3 (no dehydration) + 3 (outpatient) = 24 = LOW RISK
The patient is HIGH RISK clinically because of the finding of pneumonia on CXR. Admit.
Abx = Cefipime + Vancomycin

FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.

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

See other Paucis Verbis cards.

Thanks to Alissa and Hemal for suggesting the topic!

Reference
Friefeld AG et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93. Pubmed
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YouTube: Now you can edit your videos online!

2011-10-05T03:00:00.000-07:00

Starting September 2011, YouTube now allows you to directly edit your video online. This is especially useful for those of us who upload iPhone or other mobile phone-based videos and don't want to go through the added step of DOWNloading our video, doing minor edits, and then before UPloading to YouTube.

http://www.youtube.com/editor

They really capture the primary features which you really need:

Trimming the video (start and end)
Rotating the video
Manually changing the brightness and contrast

Trick of the Trade: Opioids for air hunger

2011-10-04T03:00:00.000-07:00

A patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen:

Oxygen by face mask
Nebulized albuterol and atrovent
Solumedrol
Bipap
Set up for possible intubation

With the Bipap mask on, the patient's subjective sense of dyspnea and "air hunger" seems to make it harder for him to tolerate the tight-fitting mask.

Trick of the Trade:
Use a small dose of IV fentanyl

A 2001 Cochrane review evaluated studies involving non-nebulized opioids to treat symptomatic breathlessness. The review found a small statistically significant improvement in subjective air hunger, although most studies were with small sample size numbers.

Reference
Jennings AL, Davies AN, Higgins JP, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev. 2001;(4):CD002066. Pubmed
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Poll: YOU are on the residency selection committee. What would YOU do?

2011-10-03T03:00:00.000-07:00

As an attending physician, you are friends with nurses and residents on social media.

One day, you are browsing through your social media page. You came across a photo of a student - a candidate applying to your program in fact - scantily clad, inebriated, dancing in a rave. The comments followed agreed on how wild he/she had partied and drank that night.

You are on the selection committee. Should this information be part of the assessment of the candidate?

Please explain your decision in the comments section.

Vacation: No post today

2011-09-30T03:00:00.001-07:00

Self-imposed, vacation day.

I'm declaring today as one of many national "Wellness" days. Have a great weekend.

Sorry for the no-post.

Keep a look out for Dr. Stella Yiu's upcoming poll regarding a student's behavior: "What you do if YOU were on the residency selection committee?"

Join.Me: A free online screenshare and phone conferencing tool

2011-09-28T03:00:00.000-07:00

Skype, FaceTime, Google+ Hangout.

So many options!

I recently used a free online tool at Join.Me so that 3 people can discuss the statistical analysis of a paper we are working on. But it's so hard to get 3 busy people in the same room at the same time! So, we tried Join.Me. We basically needed to view one shared computer to review the statistical data and share a conference call phone line.

What I was immediately impressed by was the simplicity in the whole process. It's FREE and PC-/Mac-compatible.

1. Go to the simplistically appealing home page (see above).
2. Click on the orange"share" icon.
3. This automatically downloads a software package which you should install.
4. Open the Join.Me software app on your computer.

5. A pop-up screen (above) will appear. Now click on the Share icon.

6. This will automatically give you an URL link to share with others to view your screen PLUS a free conference call line.

Here's a sample promotional image of what a session looks like:

We had a great meeting about a multicenter (11 hospitals!) educational study on the impact of an English-based pediatric software on physician decision making in Vietnam. It was super-fast, efficient, and hassle-free.

Trick of the Trade: Needlestick hotline 888-448-4911

2011-09-27T03:00:00.000-07:00

You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient's venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It's difficult to concentrate when faced with so many questions whirling in your mind.

Trick of the Trade:
Use the National Clinicians' Post Exposure Prophylaxis (PEP) Hotline - 1-888-448-4911

"The PEPline provides around-the-clock expert guidance in managing healthcare worker exposures to HIV and hepatitis B and C. Callers receive immediate post-exposure prophylaxis recommendations. Available 24/7."

Remember this is for providers who are exposed and not the lay public.

I was not only surprised to find that this national hotline is hosted by UCSF/SFGH (my home institution!) but also helmed by my friend Dr. Goldschmidt (Professor and Vice Chair, Department of Family and Community Medicine).

For more information about the National HIV/AIDS Clinicians' Consultation Corner, which staffs the PEPline, view their website at: http://www.nccc.ucsf.edu/about_nccc/pepline/

On the website, they also feature a "Warmline" at 800-933-3413, which is staffed by physicians, clinical pharmacists and nurse practitioners Mondays through Fridays, from 5 am to 5 pm (Pacific Time). They provide up-to-date information for the care of your HIV-positive patient.

Paucis Verbis: Does this DM leg ulcer have osteomyelitis?

2011-09-23T03:00:00.000-07:00

We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it's the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you'll be surprised by what you find.

Several questions come up with diabetic foot ulcers:

Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer?
Is there underlying osteomyelitis?
How can I best diagnostically work this foot ulcer up for osteomyelitis?
What is the Wagner grade of this ulcer? (I think it'd be Grade 2.)

Thanks to JAMA's Clinical Rational Examination series, there is a systematic review of diabetic leg ulcers and osteomyelitis. Here are the highlights:

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

See other Paucis Verbis cards.

Below is the Bayes nomogram to help you plot out your post-test probability based on your likelihood ratios. The example given is if your pretest probability is 25% and your LR is 10. Your post-test probability would be 80%.

Reference

Butalia S et al. Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity? JAMA. 2008; 299(7), 806-13. DOI: 10.1001/jama.299.7.806.
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Get feedback on your PPT or PDF files: Reelapp.com

2011-09-22T17:06:00.000-07:00

www.ReelApp.com

The smart folks at Zurb have come up with a clever app. This free Web-based app, called Reel, allows you to quickly collect thumbs-up/ thumbs-down votes on each slide or image. . Think of it as Slideshare with a "likes" feature added.

So if you are working on a Powerpoint, a series of images, or even PDF's and want feedback from friends and colleagues without having to email the large file around, think about uploading to Reel. What a great way of crowd-sourcing feedback.

For instance, here are my "Tricks of the Trade" lectures slides for the upcoming ACEP meeting in October. See how you can give a like or hate vote to each slide. Feedback is welcome but alas they already made me turn in the files a long while ago.

Note: This only works for still images, so movie files in my Powerpoint slides don't work.

Trick of the Trade: Pediatric ear exam

2011-09-20T03:00:00.000-07:00

Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:

Balloonimals iPhone app to grossly assess peak flow
Candleflame iPhone app to grossly assess peak flow
Eye Handbook iPhone app with pediatric fixation animation targets
Casting/splinting your buddy bear

What's your trick on performing an otoscope exam of the ears?

Trick of the Trade:
The case of the disappearing otoscope "hat"

A slight of hand can easily make the otoscope speculum disappear. Your apparent search for this missing "hat" can make it easier for you to examine the ears.

Thanks to Dr. Chris Nickson (Life in the Fast Lane) for the find!

Paucis Verbis: Legionella pneumonia

2011-09-16T03:58:00.000-07:00

Did you know that there was an unexplained spike in Legionnaire's disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic?

Since the flu season is rapidly approaching, I thought I would review what Legionnaire's disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip.

Why do we want to differentiate it from other pneumonias?
Legionnaire's disease requires reporting to your state's health department to help track for outbreaks.

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

See other Paucis Verbis cards.

More information on Legionellosis from the CDC website.

Reference
Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010 Mar;24(1):73-105. PMID: 20171547
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Trick of the Trade: Synovial lactate in septic arthritis

2011-09-13T03:00:00.000-07:00

A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. "It feels different than my RA flare."

Does this patient have a septic joint?

The difficulty in diagnosing this elusive disease is that the history, physical, and serum tests are typically unhelpful in ruling in or out the disease. See my previous Paucis Verbis card covering the 2007 JAMA review on Septic Arthritis.

Interpretation of the synovial fluid is also challenging. Generally a synovial WBC count <25K suggests a non-infectious process and a WBC count >100K suggests an infectious process.

What about everything in between 25K and 100K?

Trick of the Trade:
Check if the synovial lactate level is > 10 mmol/L.

A level >10 mmol/L is highly suggestive of septic arthritis. The calculated positive likelihood ratio (LR) from multiple studies was at least 10. The negative LR ranged from 0 to 0.45.

Although the quoted studies measured lactate using liquid chromatography, presumably our point-of-care lactate levels are equivalent, based on various sepsis studies.

How do you use the LR statistic? I'm no statistician, and so I love the Bayes nomogram. This requires me to have a pretest probability for the disease. In this case, let's say that I am moderately suspicious of a septic joint given the patient's history of rheumatoid arthritis (a known risk factor), significant joint pain, and low grade fever. I'm going to say that my pretest probability is 25% (see left column of numbers).

The synovial lactate level returns at 12 mmol/L (see middle column of numbers), which gives the patient a positive LR of at least 10.

This means that my post-test probability for a septic joint jumps way up to 80%, which practically rules-in my patient for septic joint.

Reference
Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based Diagnostics: Adult Septic Arthritis. Acad Emerg Med. 2011;18(8), 781-96. PMID: 21843213
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Poll: YOU are the clerkship director - What would YOU do?

2011-09-12T03:00:00.000-07:00

You are teaching a clerkship seminar and a student kept checking her iPhone for Facebook updates. You reminded her that she probably should not be distracted and she replied, "Well, I don't need to know ACLS. I am applying to Dermatology anyways."

You happen to be meeting the Dermatology Program Director later that day...

Please feel free to type in your comments below to explain your answer.

Paucis Verbis: Distracting injuries in c-spine injuries

2011-09-09T03:00:00.000-07:00

"Distracting injury" is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of "distracting injury". Although both are studies at different sites, both conclude the same:

Chest injuries may be considered "distracting injuries" because of their proximity to the cervical spine.

So let's say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a "long bone fracture"), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might consider this patient to have a "distracting injury" because of the long bone fracture. Instead, the literature now supports your clinically clearing the cervical spine without imaging.

Wait, let's rethink this. Does this mean that you should get cervical spine imaging for ALL blunt trauma patients with ANY chest wall tenderness?! NO. That's just crazy. You should still factor in the mechanism of injury, severity of pain, and your clinical gestalt.

So for me, these "distracting injury" studies are helpful such that:

If your trauma patient does NOT have chest trauma, it may help you avoid unnecessary cervical spine imaging, as suggested by the NEXUS criteria.
If your trauma patient DOES have significant chest trauma, I have a lower threshold to obtain cervical spine imaging despite the neck being non-tender.

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

See other Paucis Verbis cards.

Brief survey: Need your help with my promotions!

2011-09-07T03:00:00.000-07:00

With all of the advances in technology and social media, the "old school" world of traditional academia doesn't know what to do with medical professionals who incorporate technologies into their educational practices. To justify these past 2 years of blogging during my free time, I wanted to collect data on who my readers are and the impact of my blog (if any).

I could sure use a few minutes of your time and input to help with my promotions process. Let's push traditional academia to change with the times. Thanks a bunch.

UPDATE (9/9/11): Wow, I am overwhelmed and humbled by everyone's kind words. This survey alone illustrates the power, reach, and immediacy of social media. I've gotten 147 responses already! (see responses on Google Docs Forms). Now I know for certain that I am on the right track in pushing for social media technologies in medical education.

<p>&amp;amp;amp;lt;p&amp;amp;amp;gt;&amp;amp;amp;amp;amp;amp;amp;lt;p&amp;amp;amp;amp;amp;amp;amp;gt;&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Loading...&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;&amp;amp;amp;amp;amp;amp;amp;lt;/p&amp;amp;amp;amp;amp;amp;amp;gt;&amp;amp;amp;lt;/p&amp;amp;amp;gt;</p>

This is the first time I have used Google Docs Forms to build a survey. Pretty cool.

Trick of the Trade: Epley maneuver

2011-09-06T03:00:00.000-07:00

You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.

Is your first-line treatment meclizine or benzodiazepines?

Trick of the Trade:
Epley maneuver (Canalith Repositioning Procedure)

Although the 2004 Cochrane review states that the Epley maneuver is of questionable benefit, a 2010 systematic review demonstrated that there is a significant benefit from Epley maneuver. The trick is remembering all of the steps correctly.

The first position is really the Dix-Hallpike maneuver in the direction (right vs left) which causes more vertigo or nystagmus.
Wait 30-60 seconds.
While remaining supine with the head extended 25-30 degrees, rotate the head 90 degrees until it is facing the other shoulder.
Wait 30-60 seconds.
Have the patient cross his/her knees and arms.
Have the patient roll onto his/her side (same side as looking towards) while keeping the head facing the shoulder. This positions the face so that it is almost now facing the floor. If done correctly, this should exacerbate the vertigo because the canaliths are repositioning themselves.
Wait 30-60 seconds.
Assist the patient in sittting up by swinging their legs off the edge of the table and sitting up "like a windshield wiper".
Lastly, have the patient look downward around 30 degrees.

You can recommend that your patient look at YouTube videos at home to help remind them of the steps that they can do at home every night.

Reference
Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010 May;90(5):663-78.

Paucis Verbis: Antibiotics for Cystitis & Pyelonephritis in Women

2011-09-02T03:00:00.001-07:00

You diagnose a 35 years old woman with uncomplicated cystitis. She is not diabetic and not pregnant. Which antibiotics should you give? What if she had pyelonephritis?

Answer: It depends on your local antibiogram.

Today, go find out about your hospital's local resistance rates for uropathogens to various antibiotics. For San Francisco General Hospital, I found our 2010 antibiogram publicly posted online. Urine isolates of E. coli demonstrate relatively high resistance rates to trimethoprim-sulfamethoxazole and ciprofloxacin:

Trimethoprim-sulfamethoxazole resistance rate = 33%
Cefazolin or Cephalexin resistance rate = 12%
Ciprofloxacin resistance rate = 16%

So based on the new 2010 practice guidelines by the ID Society of America and the European Society for Microbiology and Infectious Diseases, I should give:

Cystitis: Nitrofurantoin x 5 days, or cephalexin / beta-lactam x 3-7 days
Pyelonephritis: Ceftriaxone 1 gm IV x 1 + (ciprofloxacin x 7 days or trimethoprim-sulfamethoxazole x 14 days)

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

See other Paucis Verbis cards.

Reference
Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE, Infectious Diseases Society of America, & European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases. 2011; 52(5). PMID: 21292654
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Trick of the Trade: Dix-Hallpike maneuver

2011-08-30T03:00:00.001-07:00

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!

2011-08-29T03:00:00.000-07:00

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

2011-08-26T03:00:00.000-07:00

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

2011-08-23T03:00:00.000-07:00

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

2011-08-23T02:55:00.000-07:00

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!

2011-08-22T03:00:00.000-07:00

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

2011-08-19T03:00:00.000-07:00

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

2011-08-16T03:00:00.000-07:00

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

2011-08-15T03:00:00.000-07:00

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

2011-08-12T03:00:00.000-07:00

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

2011-08-11T03:00:00.001-07:00

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

2011-08-10T03:00:00.001-07:00

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

2011-08-09T03:00:00.000-07:00

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

2011-08-08T03:00:00.000-07:00

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

2011-08-05T03:00:00.000-07:00

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)

2011-08-04T03:00:00.000-07:00

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

2011-08-03T03:00:00.000-07:00

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)

2011-08-02T03:00:00.000-07:00

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

2011-08-01T03:00:00.001-07:00

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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Paucis Verbis: Fibrinolytics for PE

2011-07-29T03:00:00.001-07:00

When would you give fibrinolytics for a

Pulmonary Embolism?

This Paucis Verbis card summarizes recommendations found in Circulation's recently published Scientific Statement from the American Heart Association. Although it is rare to give fibrinolytics for a pulmonary embolism (PE) in the Emergency Department, it is important to remember when lytics are indicated.

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

See other Paucis Verbis cards.

Reference
Jaff MR, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830. Pubmed.
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New guest blogger: Dr. Hans Rosenberg

2011-07-29T02:59:00.000-07:00

Dr. Hans Rosenberg

Let's make it official. Dr. Rosenberg has been contributing great content for this site. We're honored to have him officially join our blogging team!

Dr. Rosenberg did his residency at the University of Ottawa, graduating in 2009. He now works at the Ottawa Hospital Emergency Department as a Consultant Staff Physician and is an Assistant Professor at the University of Ottawa. His interests in medical education are specifically related to our interaction with technology and how we use it to learn, educate and improve our practice of Emergency Medicine.

Inspirational graduation speech by Conan

2011-07-28T03:00:00.000-07:00

I found this inspirational 2011 graduation speech by Conan O'Brien at Dartmouth College. It is a great mix of silly, witty, inspirational, and profound. Check it out. For those in Medicine and medical training, your dreams may change over time... and that's ok.

"Your perceived failure can become a catalyst for profound reinvention."
-- Conan O'Brien

"No specific job or career goal defines me, and it should not define you."
- Conan O'Brien

Trick of the Trade: Making a beanie hat

2011-07-27T03:00:00.000-07:00

Scalp lacerations are a common condition in the Emergency Department. Some require no bandage over once the injury is repaired. Because the scalp is so vascular, others require a pressure dressing over the site to minimize hematoma formation.

How do you bandage these patients? It is difficult to secure any wrap or square gauze over the site, because the head is round and the hair is slippery.

Trick of the Trade:
Make a snug-fitting beanie hat using tubular gauze.

Find the appropriate size tubular gauze. It should fit snuggly over the patient's head when fully stretched open. Start with a 1-foot long piece of tubular gauze. Tie a knot on one end. This will sit at the vertex of the patient's scalp.

Create 2 tails by cutting longitudinally along the tubular gauze.

Pull the tubular gauze over the patient's scalp. Usually patients won't look this giddy-happy during this process.

Secure the two tails under the patient's chin.

This technique allows you to rest several layers of 4x4 inch gauze over the laceration site as pressure dressing. The tubular gauze stabilizes it in place without any tape.

Thanks to Dr. Eric Silman (UCSF-SFGH EM chief resident) for the idea and photos!

SAEM 2012 Consensus Conference: Education Research in EM

2011-07-26T03:00:00.000-07:00

It has just been announced that the upcoming 2012 SAEM annual meeting will feature a full-day Consensus Conference on Education Research in Emergency Medicine. In the past, Consensus Conferences have focused on such areas as "Interventions to Assure Quality in the Crowded Emergency Department" and "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise".

There's introductory information on the SAEM Facebook page. The format is a bit cluttered, so I am reposting here below:

2012 Academic Emergency Medicine Consensus Conference

“Education Research in Emergency Medicine:

Opportunities, Challenges and Strategies for Success”

The 2012 Academic Emergency Medicine Consensus Conference, “Education Research in Emergency Medicine: Opportunities, Challenges and Strategies for Success” will be held on May 9, 2012, immediately preceding the SAEM Annual Meeting in Chicago, Illinois. Original papers on the conference topic, if accepted, will be published together with the conference proceedings in the December 2012 issue of Academic Emergency Medicine.

A divide has traditionally existed in academic medicine between the educator and the researcher. The goal of this conference is to bridge this gap, by exploring the principles that guide these two allied disciplines to create a unified focus on education research science that will benefit our teachers, our learners and ultimately our patients.

Emergency medicine (EM) educators have long perceived the need for better research to guide the frequent challenges encountered in the academic environment. These include identifying best practice teaching methods, validating assessment tools, evaluating competency, and preventing cognitive errors. Efforts to address these challenges have begun; however the historical use of suboptimal study designs, subjective outcomes, small samples sizes, and lack of expertise in methods useful in other domains can limit the success of education research studies. A coordinated agenda for EM education research is needed to address these topics and streamline our research efforts.

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project now mandates that training programs demonstrate the effectiveness of educational interventions and show evidence of trainee aptitude and achievement in the core competencies. The American Board of Emergency Medicine (ABEM) now requires its diplomats to provide evidence of Assessment of Practice Performance in order to receive continuous certification. These and other requirements highlight the current paucity of available evidence to inform our instruction and evaluation of emergency physicians, and call for our field to develop high-quality education research.

A systematic approach to education research in EM is essential for the continued improvement of clinical emergency care, even for providers beyond residency training. In the decade since the Institute of Medicine's 2001 "Crossing the Quality Chasm" report identified the failure of health care environments to consistently deliver evidence-based care, the increased emphasis on translational research and patient safety has identified even broader needs for education-based research. Without well-designed studies to investigate the most effective methods to teach and evaluate emergency physicians, scientific discoveries cannot be effectively disseminated to physicians in training or in practice, nor the benefits fully realized by our patients.

This Consensus Conference on Education Research in Emergency Medicine proposes to build a solid foundation upon which EM education researchers can build interdisciplinary scholarship, networks of expertise, discussion forums, multicenter collaborations, evidence-based publications and improved learner education. Such efforts will enable us to make significant contributions to the state of knowledge in medical education and, ultimately, to optimize patient care.

Consensus Conference Goals:

Provide an overview of the current state of education research in EM
Identify and examine the barriers that educators face in conducting well-powered, rigorous education research, and develop recommendations for overcoming these barriers
Define most appropriate and effective methods for conducting education research studies
Identify priority agenda areas within specific education research domains, such as:
Establishing the effectiveness of clinical and didactic curricula in educating EM trainees in each of the six ACGME core competencies
Evaluating performance of learners across the continuum of medical education, from medical student to practicing emergency physician
Validating educational assessment tools
Teaching and evaluating non-cognitive ACGME core competencies, such as “Professionalism” and “Interpersonal and Communication Skills”
Measuring the impact of educational interventions to improve patient safety
Research designs conducive to studying education outcomes
Develop a framework to increase collaboration, access to research support and potential funding sources and promote faculty development in education research

Original contributions describing relevant research or concepts on this topic will be considered for publication in the December 2012 issue of Academic Emergency Medicine if received by Monday, March 12, 2012. All submissions will undergo peer review and publication cannot be guaranteed. For queries, please contact Nicole DeIorio, MD (deiorion@ohsu.edu), Joseph LaMantia, MD (JLaManti@nshs.edu), or Lalena Yarris, MD (yarrisl@ohsu.edu), Consensus Conference Co-chairs. Information and updates will be regularly posted in Academic Emergency Medicine, the SAEM Newsletter, and the journal and SAEM websites.

Article review: Message for new generation of educators

2011-07-25T03:00:00.001-07:00

An interesting article was published in Medical Education which you don't see too often in journals. It's a first-person reflective account of Dr. Ronald Harden's long and internationally well-regarded career in medical education. No p-value. No sample size calculation. His experiences and lessons learned provide great insight. Here's his advice to current and future educators.

1. People are important.

Be a great clinician-educator role model for learners.

2. Innovation in medical education is complex.

Beware of confounding factors and bias.

3. Nudges are important.

Because medical education is a social discipline, be subtle in how you make changes. Small changes or recommendations play better than large, sweeping changes and top-down mandates.

4. Students are important as players.

Today's students are different from students 10 years ago. Today's students are "digital natives." Personalized curricula will be important because every student has different needs.
"It is important to have as the aim directed self-learning rather than self-directed learning." That means educators should provide some structural framework in how students conduct independent learning.

5. Offer practical solutions to problems.

6. There is always something to learn outside one’s practice.

Attend an education conference outside of your specialty. To make real progress in medical education, there needs to be better cross-collaboration.

7. Publish.

"If I had to live my life again I would place greater priority on documenting what I did and publishing it."

8. Learn from history.

Don't reinvent the wheel.

9. Obtain independent funding.

Although it is very challenging to obtain external funding, it forces one to be clear and concise about why one's study is important and how it should be conducted.

10. Have fun!

Reference

Harden RM. Looking back to the future: a message for a new generation of medical educators. Medical Education. 2011;45(8), 777-84 PMID: 21752074
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Paucis Verbis: Diagnostic testing tips for acute abdominal pain

2011-07-22T03:00:00.000-07:00

In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.

My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead -- more accurate and less radiation.

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

See other Paucis Verbis cards.

Reference
Panebianco NL, Jahnes K, Mills AM. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin N Amer . 2011;29(2):175-93. PMID: 21515175
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Advice for the new EM interns

2011-07-21T03:00:00.000-07:00

One of my favorite blogs, Better in Emergency Medicine, by Dr. Rob Cooney reviewed the 1991 article entitled "The Ten Commandments in Emergency Medicine". These commandments are timeless and still hold true today. Rob gives a helpful review of each commandment's relevance in today's ED.

1. Secure the ABC's
2. Consider or give naloxone, glucose, and thiamine
3. Get a pregnancy test
4. Assume the worst
5. Do not send unstable patients to radiology
6. Look for common red flags
7. Trust no one, believe nothing (not even yourself)
8. Learn from your mistakes
9. Do unto others as you would do to your family (and that includes coworkers)
10. When in doubt, always err on the side of the patient

Tricks of the Trade: Underwater ultrasonography

2011-07-20T03:00:00.000-07:00

I've heard of underwater basketweaving, but underwater ultrasonography?

Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient's extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient's skin and transducer. What's a quicker and easier way to create some distance yet preserve image quality?

Trick of the Trade:
Submerse both the body part and the ultrasound transducer under water.

For this "bath water technique", start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.

Thanks to Andy at Emergency Medicine Ireland blog for these 2 ultrasound images!

This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient's wound.

Reference
Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267
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TED-Ed Brain Trust: "Catalyzing an education revolution"

2011-07-19T03:00:00.000-07:00

If you have not heard of TED videos, I highly encourage you to view them. They are short, inspirational, and professional talks by leaders, scientists, and artists, who focus on bringing together the 3 worlds of Technology, Entertainment, and Design.

Because many of these videos focus primarily on education, TED has just built a new online community of educators called the "TED-Ed Brain Trust". The mission is to bring together "the expertise of visionary educators, students, organizations, filmmakers and other creative professionals to guide, galvanize and ultimately lead this exciting new initiative."

Registration to join the Brain Trust is free and open to the public. Below is a Prezi presentation explaining the vision for TED-Ed. Click on the right arrow to view the presentation.

Article Review: Redesigning a Powerpoint lecture using multimedia design principles

2011-07-18T03:00:00.000-07:00

Let's rethink how we design our Powerpoint slides. Let's create design principles using Mayer's cognitive theory of multimedia learning.

Cognitive Theory of Multimedia Learning
In a nutshell, people learn through two channels -- words and images. This dual-channel theory suggests that people process auditory and visual stimuli separately. Each channel requires time to process information before merge into a cohesive cognitive concept.

Dual Channel Theory for Multimedia Learning

(click to enlarge)

Based on this dual-channel theory, Mayer developed some key principles in designing multimedia materials. The key is to minimize cognitive load, or the burden on one's working memory during instruction. Some examples from the highlighted article include:

Make the message stick: Simplify using images. Get the message across by making the header a sentence rather than a phrase. Avoid bullet points.

Signaling principle. Highlight only the essential material.

Coherence principle. Avoid distractors and eliminate unnecessary words, pictures, and sounds.

In a prospective study this month from Medical Education, traditional Powerpoint slides were compared to modified Powerpoint slides in a lecture on Shock. The content remained the same. The modified Powerpoint slides implemented Mayer's multimedia design principles. Many other principles are nicely summarized at Design eLearning blog. A convenience sample of Surgery clerkship third-year medical students were enrolled (n=39 traditional, n=91 modified).

Based on a pre-test/post-test design, the authors found that the students were able to recall facts better (eg. "Define shock.") using the "modified" Powerpoint slides. Interestingly, the "modified slides" students did not perform any better than the control group in their ability to transfer their knowledge in written clinical vignettes.

This was a great study. I hope they pursue this line of inquiry. More studies need to look at using multimedia effectively for teaching.

In the meantime, I am definitely going to be reading more about Mayer's work.

Reference
Issa N, Schuller M, Santacaterina S, Shapiro M, Wang E, Mayer RE, Darosa DA. Applying multimedia design principles enhances learning in medical education. Medical Education. 2011; 45(8), 818-26. PMID: 21752078
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Paucis Verbis: NSAIDS and upper GI bleeds

2011-07-15T03:00:00.000-07:00

Primum non nocere.

Do no harm.

We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?

Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don't have a history of a GI bleed or peptic ulcer.

You can download this PV card: [MS Word] [PDF]
See other Paucis Verbis cards.

Reference
Massó González EL, Patrignani P, Tacconelli S, García Rodríguez LA. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis and Rheumatism. 2010;62(6), 1592-1601. PMID: 20178131
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Doing well as a new EM attending physician

2011-07-14T03:00:00.000-07:00

You are super-excited to get your first real job as an emergency physician after residency. Then this immediately turns into a nauseating, super-terrified feeling, right?

After posting two entries [1, 2] to help medical students do well on their EM clerkship rotation, a commenter suggested that I provide a list of tips for doing well as a new EM attending physician. Although there is slightly variation for community versus academic faculty, many of the basic tenets hold true:

1. Be an accurate charter.
Let's face it. In the end, departments are driven by money. Don't let the department leadership think that they are losing money on you. So, if you do the bedside ultrasound, do a critical care resuscitation, or suture a simple laceration, chart it. It's good for billing, and it's good for medicolegal reasons. Documentation is key. I'm not saying to overbill but rather to be accurate in what you chart.

2. Be nice to the nurses.
This is the same advice I always give to students and residents on the EM rotation. Coming into a new practice environment is difficult by itself. The nurses can make it less... or more challenging. Take a minute to introduce yourself to those who you don't know. Be approachable. Keep them apprised of the patient's overall plan. Personally, I brought candy on my first shift, and that tradition has never quite gone away.

3. Get to know key players in and out of the ED.
Over time, get to know the consultants, radiologists, radiology technicians, custodial staff, and ancillary staff. This smooths-over many of the intangible hurdles that we encounter on a day to day basis in the ED.

4. Be a role model.
You now represent the face of the department for patients, nurses, consultants, and residents/students (if you have any). Don't be late. Be cognizant of where you voice informal comments. Someone impressionable is always listening.

5. Familiarize yourself with the resuscitation equipment before starting your first shift.
You may be the world's intubation expert, but if you can't figure out where the spare endotracheal tubes and laryngoscopes are, things go bad quickly.

6. Realize that you are working in a different ED.
Every Emergency Department has its little quirks. Nothing irritates people than someone new, who constantly reminds others that "When I was at _____, we did it this way." Try to figure out how your ED handles different scenarios. Examples at my hospital include:

Patients with pancreatitis often get admitted to our Surgery service and not Internal Medicine.
On the weekdays, trauma airways are managed by an Anesthesia resident and not an EM resident.
Our ED tends to prescribe only vicodin and percocet (and rarely oxycodone or darvocet).

7. Decide on how you want to access clinical information.
You won't know the solution to every problem in the ED. There's something that surprises me every day. That's the upside and downside of EM. I admit that in my first year, I called my residency program's ED to "curbside" an attending once. Decide on how you want to be able to look up information. Will it be by using:

PEPID?
Epocrates/Micromedex mobile app?
UpToDate?
EMedicine.com?

8. Keep up to date with the literature.
It is all about lifelong learning. Learning does not stop after residency. Devise a plan to keep apprised of the major updates. This might include doing one or several of the following:

Subscribing to a few journals. I personally read Annals of EM, Academic EM, and EM Clinics of North America.
Attend an occasional national meeting.
Subscribe to various podcasts, videocasts, or online websites such as EM-RAP, CME Download, or Emedhome.com, respectively. [Disclosure: I am not affiliated with any of these products.]
If you are a community emergency physician, attend a few EM residency conferences in your area. I'm sure they'd appreciate your insight from a non-academic site perspective.

Any other suggestions that you can think of?

Trick of the Trade: Anesthetizing the nasal tract

2011-07-13T03:00:00.000-07:00

One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness.

Trick of the Trade:
Targeted approach using viscous lidocaine on Q-tips

Put copious amounts of viscous lidocaine on the cotton end of a long Q-tip. Slide the Q-tip into the nose along the NG tube or NP scope tract. When you feel the end of the swab reach resistance and/or the patient has discomfort, stop advancing the Q-tip. Twirl it to spread the lidocaine. Leave it there for a few seconds until they can't feel the Q-tip anymore. Then advance and repeat until you get to the back of the nasopharynx. You may need to reload the Q-tip with more lidocaine. This technique applies lidocaine to the most sensitive areas while also testing for anesthetic effectiveness.

You can supplement this technique with nebulized lidocaine to anesthetize the posterior oropharynx to minimize the gag reflex.

Thanks to Dr. Adrian Flores (UCSF-SFGH EM resident) for this great idea!

Emergency Medicine factoids on Twitter

2011-07-12T03:00:00.000-07:00

The medical profession is slowly incorporating Twitter. If you have a Twitter account, here are some great Twitter accounts to follow:

@EM_PEARLS

Written by Dr. Brian Kloss (EM faculty at SUNY Upstate Medical University)
EM nuggets of wisdom, targeted for medical students, EM residents, and mid-level practitioners

@EMEducation

Written by Dr. Rob Cooney (EM faculty at Conemaugh University) and of Better in Emergency Medicine blog fame.
Written in a question-answer format, this account provides great pearls targeted for EM residents.

@CDEMUpdates

I created this account a few years ago but never really did anything with this. The CDEM (Clerkship Directors in EM) organization is now more formally organizing our social media team.
Written by a team of CDEM faculty, this account targets medical students on their EM clerkship rotation.

Any other Twitter account suggestions?

New website for medical education researchers

2011-07-11T03:00:00.000-07:00

There is a great new website "Medical Education Subject Guide", hosted by UCSF's own Josephine Tan, tailored to medical education research and academic scholarship. I've been a long-time admirer of Josephine's work as an Education and Information Consultant in Clinical Sciences for the UCSF Library.

This compiles and lists helpful resources, which include books, journals, databases, multimedia resources, organizations, literature search tips, and blogs. The site also links to her two blogs:

Medical Education Literature Searching

Literature searching tips and educational insights

In Plain Sight

This blog provides information searching and citation management tips, as well as educational insights to enhance the faculty, researcher, clinician, and student information seeking, management, presentation, and publication experience.

Wish I had these resources when I became interested in medical education and education research...

Paucis Verbis: Cardiac tamponade or just an effusion?

2011-07-08T03:00:00.000-07:00

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it's relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it's equivocal? How good is the clinical exam and EKG in ruling out a tamponade?

Answer: Poor to average, at best. The Beck's triad of hypotension, distended neck veins, and muffled heart sounds are important to remember ... only on tests.

Solution: Think about performing a pulsus paradoxus test to see if it's >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.

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

See other Paucis Verbis cards.

Take a look at this helpful video demonstrating how to measure pulsus paradoxus.

Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!

Reference
Roy C et al. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA: The Journal of the American Medical Association. 2007; 297(16): 1810-8. DOI: 10.1001/jama.297.16.1810
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Joining the Facebook age

2011-07-07T03:00:00.001-07:00

With the recent "awesome" news about Facebook teaming up with Skype for video chatting yesterday, I thought it was time for the blog to also join the Facebook world. Thanks to Dr. Hans Rosenberg for pushing me to do this.

I finally created Academic Life in Emergency Medicine's Facebook Page. I think that it works. By clicking on the Facebook "Like" icon in the right column of this blog, your Facebook stream should import each blog post automatically. Suggestions for improvement on the Facebook Page are welcome.

Building the page was a rather user-UNfriendly process. Briefly, here are the steps if you are interested in building your own Facebook Page.

1. After creating a Facebook Page, click on Edit Page button in the upper right.

2. From the left column, select "Apps". One of the apps is "Notes". Click on "Go to App" under Notes.

3. In the bottom left column, click on "Edit Import Settings". This will then ask you to enter the URL of the blog that you want to import.

Trick of the Trade: Epistaxis control with tongue blades

2011-07-06T03:00:00.001-07:00

For epistaxis, the classic teaching is to pinch the nose to control the bleeding. A persistent nosebleed often is the result of one's natural inclination to constantly check if there is still bleeding every few seconds. Applying pressure on-and-off makes it difficult for the bleeding to stop.

Trick of the Trade:
Use tongue blades to pinch the nose.

Don't rely on the patient to apply constant pressure to the nose. It is too tempting to intermittently check for bleeding. Instead create a "nose pincher" by taping the end of two tongue blades together (at the level of the green arrow). Wedge the nose between the open ends. Leave the tongue blades in place for at least 20 minutes.

The photo is courtesy of my friend Dr. Matthew Lewin.

A faculty's perspective: Doing well on your EM clerkship

2011-07-05T02:55:00.000-07:00

To follow-up with Dr. Connolly's post about the Top 10 tips for medical students to rock the EM clerkship rotation, I thought I would post some additional tips. Here are some more pearls:

11. Take ownership of your patients.
This means that you should take it upon yourself to make sure that your patient's care is stellar, addresses key clinical and social issues, and is timely. Constantly check for your patient's results. Don't be the last to hear of your patient's lab or imaging results. Figure out why there are unexpected delays. Address any psychosocial issues which may hamper your patient's clinical improvement in the ED.

12. Have a learning plan on shift.
It's helpful to yourself and others to have a focused learning plan for each shift. For instance, this might be -- I want to get better at reading plain films. Let the senior resident and attending know. This fulfills two purposes. First, you'll likely get pulled in to view and read films even though they might not involve your patient. Usually the senior resident or attending will keep a lookout for interesting findings. Second, this shows that you are an active learner who is seeking out learning opportunities rather than letting them passively and randomly occur.

13. Don't be late to your shift.
'Nuff said.

14. In addition to trauma shears, carry a very bright pen light.
A bright light source comes in handy all the time. I use a bright LED pen light and I constantly use it on shift. This works well especially when trying to examine for laceration, foreign bodies, and other such injuries.

15. Befriend the nurses.
This is a good general rule of thumb for everyone. The nurses are a key part of the medical team and have great clinical gestalt about what is going on with the patients. Introduce yourself to them at the start of your shift. Listen seriously to their concerns and comments. They are a wealth of wisdom and can help answer many of your questions.

16. Clean up your sharps and equipment after procedures.
This is a corollary to rule #15.

17. Start learning about bedside ultrasonography.
This bedside tool is constantly being used in the Emergency Department an. Read up a little on the more common types of ultrasound exams. The most common are probably vascular ultrasounds for central line access and the FAST exam. If you can, try to get some hands-on experience on your cases. Hey, maybe your learning plan for one of your shifts might be to become more adept at bedside ultrasonography!

Good luck to the new MS4 medical students!

Happy 4th of July

2011-07-04T03:00:00.000-07:00

Be safe and PLEASE stay out of the Emergency Department.

Paucis Verbis: Blunt cerebrovascular injuries

2011-07-01T03:00:00.000-07:00

In the setting of blunt trauma, it is easily to overlook a patient's risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke.

Who are at risk for these injuries?
What kind of imaging should I order to rule these injuries out?
Do I really treat these patients with antithrombotic agents even in the setting of trauma to reduce the incidence of CVA?

FYI: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit probably need imaging.

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

See other Paucis Verbis cards.

Reference
Burlew CC, Biffl WL. Imaging for blunt carotid and vertebral artery injuries. Surgical Clinics of North America. 2011, 91(1), 217-31. PMID: 21184911
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An intern's perspective: Doing well on your EM clerkship

2011-06-30T03:00:00.000-07:00

It's that time of year again. When medical students interested in EM are stressing over doing well on their EM rotation.

Here's a very insightful guest post from Dr. James Connolly, who is a new PGY-1 resident at Hahnemann Hospital in Philadelphia, and hosts his own blog at: www.erjedi.com. I'll write my personal top-10 list next week, from the perspective of a faculty member.

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Many MS4 interested in emergency medicine will be starting their EM Sub-I's in the next few weeks and are naturally wondering what to expect, and how they can be successful, both in terms of getting a strong letter of recommendation, and all while still having a fun and enjoyable rotation. With that in mind, I'd like to present a unique "Top Ten" list, written with the aim of helping the student succeed on his or her upcoming rotation. The list is my own, based on my experiences during three EM rotations last year as a medical student. I've also asked a few of my fellow interns for their input on the list, so the list really reflects thoughts of a handful of people who recently successfully matched into emergency medicine.

1. Case files or a similar book will cover 99% of what you need to know. But remember, this is not like a medicine rotation where you can go home and read about your patient at night and then use what you learned the next day on your patient. Avoid UpToDate if you need to look something up as it will give you WAY more information that you probably need. Instead, there should be a copy of Tintinalli's Emergency Medicine or even better "5 Minute Emergency Medicine Consult" laying around to look up something quick if you need to.

2. If you had to know three cases cold, know about chest pain, belly pain and asthma, the differential and basic treatment of each. You will probably see each of these on every shift. There are also a few "rules" that if you know them, you'll be on your way to all-star status. The ones I was asked about most were rules for head CT imaging, C spine clearance, and PERC scoring for pulmonary embolism.

3. Don't worry about trauma, no one has expectations for you to know much, if anything, about what to do when a trauma patient rolls in.

4. Despite that, still gown up for trauma. You might be able to get involved, you might not. But if you don't wear your uniform, the coach can't put you into the game.

5. Keep a pair of trauma shears in your back pocket. Helping to cut clothes is a great way to get up to the table during trauma cases, and you'd be surprised how often you'll need a pair of scissors during your shift.

6. Practice your instrument ties and simple interrupted sutures ahead of time and feel confident knowing how to do them.

7. Before presenting your patient, take 2 minutes and practice it to yourself. Remember that these presentations are different than your medicine presentations. What the patient had for breakfast or the last time they pooped probably don't need to be included.

8. Practice your presentation. Its worth repeating. In the busy ER, the amount of "face time" you get with those who will be evaluating you largely consists of you presenting your patients, especially during a busy shift. This is the best opportunity to show your stuff, so if you can appear polished, it will only help. If you present to the attendings, try to run it by your third-year resident first for an additional practice run.

9. When you present, be prepared to answer the question "So what do you want to do?" In other words, have a plan in mind of how you want to proceed with this patient.

10. Review the basics of normal EKGs. You will likely be asked to interpret several EKGs, most of which will likely be normal. Thus, know what makes an EKG normal (ie Sinus rhythym, regular rhythm, correct intervals and timing etc etc)

Bonus point: Enjoy the rotation. In all of med school, no other rotation will let you be an independent thinker (and often worker) like your EM rotation will. Use this as a chance to apply all that great knowledge you've been building up over the years.

Read more on tips for success from a faculty perspective.