An intern's perspective: Doing well on your EM clerkship


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.

Trick of the Trade: A mini-suction device


You are doing a shift in the pediatric ED and you are evaluating a kid with a small bead in her ear. There are a ton different approaches you can use (eg. tissue adhesive glue on a q-tip stick). If the bead is in too deep, blindly trying to adhere the foreign body to the glue is a bit risky. Sometimes applying gentle irrigation might not be enough to wash out the bead. You want to avoid irrigation if you worry about a tympanic membrane rupture.





Trick of the Trade: 
Build a mini-suction device using part of a butterfly needle.
  • Cut off the back end of a butterfly needle, leaving about a 2-4 cm tail off of the white plastic hub.
  • Tightly wedge the hub into a suction hose.
  • Turn on the suction.



Thanks to Dr. Liz Brown (UCSF-SFGH EM resident) for this fantastic idea.

TED video: Turning medical education inside out and upside down




Dr. Lawrence Sherman is an innovator in Continuing Medical Education. He is Senior Vice President of Educational Strategy for Prova Education, past member of the Board of Directors of the North American Association of Medical Education and Communications Companies (NAAMECC), and has served as an appointed member of the Professional Education Committee of the American Heart Association.

He talks about how we should build medical training that is patient-centered so that students would feel comfortable interacting with actual patients from day 1 of medical school training. The speaker is stylistically a bit over-the-top with his expressions and mannerism, but the ideas are novel and relevant in medical education.

Article review: Carnegie's vision for medical education


In 2010, the Carnegie Foundation for the Advancement of Teaching published recommendations for the future reform of medical education. This same Carnegie Foundation had also commissioned and published the landmark 1910 Flexner report on medical education, exactly 100 hears prior.

Here is a summary of the four major recommendations:

1. Standardization and individualization
Competency-based education is the future. Students enter medical school with a diverse background of knowledge and experiences. The focus should be towards achieving goals within the competency framework, rather than finishing four set years of medical school. Once you achieve each competency, you can move on. For instance, why does a medical student with a PhD in Statistics have to enroll in the mandatory first-year course on "Introduction to Statistics"? That person should just be able to "test out" and spend that time learning more about anatomy, for instance. Curricula should be individualized and tailored to the learner. The same case could be made for residency education, as well.

2. Integration
Clinical medicine needs to be part of medical school education from day 1, instead of just the second-half of medical school. It also needs to be integrated with the basic and social sciences. Innovative programs include longitudinal integrated clerkships which do away with the traditional block rotations and instead have students follow a set group of patients over the year. A few schools actually start with clinical education and then incorporate basic science courses later.

3. Habits of inquiry and improvement
Learning doesn't stop after you graduate from medical school and residency. Learners should be encouraged to constantly ask questions, learn, and innovate.

4. Identity formation
Learners should be encouraged to take responsibility as a physician with high standards for knowledge, skill, and professionalism. This can be done through various rituals (eg. white coat ceremony), self-reflection, mentoring, and feedback. Occasionally, unprofessional behavior by medical providers occurs in reality and undermines this mission. It is critical that the medical community maintain a culture of respect, collaboration, and professionalism because impressionable eyes are watching.

Reference
Irby D. Educating physicians for the future: Carnegie's calls for reform. Medical teacher. 2011, 33(7), 547-50. PMID: 21696280
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Hypopyon

A hypopyon is a pus collection within the anterior chamber of the eye.Patients will present with pain, irritation, itchiness of affected eye. Some may have decreased visual acuity or photophobia. This patient did not have decreased visual acuity or photophobia other than the limited visual field besides the pain and irritation.It is not a disease per se, but a presentation of diseases. It can

The Rule of Six in Infusion Part 2 - The Pros and Cons

For the last one week, there has been some interesting discussion in my group on the use of the rule of six for infusion. I have previously written a blog post on this.According to an article (click here to access), the rule of six is not optimal for patient safety - which I sincerely agree. Some of the points raised in that article:1. the rule of 6 is not followed consistently. Some

Paucis Verbis: Clostridium Difficile


I just finished taking the 2011 LLSA exam to remain eligible for recertification. The only good thing about this test is that it gives me interesting topics for my Paucis Verbis cards.

Here's a card on a disease process that is becoming increasingly prevalent -- Clostridium difficile. This is a summary based on the 2010 guidelines by Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).

Because healthcare workers are often the culprit for transmitting C. difficile to other patients, be sure you wash your hands with soap and water really well. Wear gloves. Be aware that alcohol-based hand rubs (eg. hand sanitizers) are ineffective in killing C. difficile spores.


References
Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010 May; 31(5):431-55. PMID: 20307191
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TED video: Apps in Medicine



Dr. Daniel Kroft talks gives us a glimpse into how he envision the future of Medicine with today's technology. Dr. Kroft is board certified in Medicine and Pediatrics, chairs the Medicine track for Singularity University, and is Executive Director and curator for the FutureMed, a program which explores convergent, exponentially developing technologies and their potential in biomedicine and healthcare.

It's a world of amazing game-changing possibilities.

Trick of the Trade: Cunningham maneuver for shoulder dislocation


We commonly see patients with shoulder dislocations in the Emergency Department. There are a myriad of approaches in relocating the joint, which includes scapular rotation, Snowbird, and Kocher maneuvers.

I recently stumbled upon the Cunningham technique after hearing about it from Dr. Graham Walker (of MDCalc fame) on TheCentralLine.org. There are some amazing videos from the ShoulderDislocation.net which illustrate how the maneuever works.

The underlying concept of the Cunningham technique is that lengthening and relaxing the spasmed biceps muscle allows for the humeral head to spontaneously slide just over the glenoid rim and back into the glenohumeral joint socket.

I was a little skeptical when reading this technique, but the videos are quite convincing.

Tips:
  • Build trust with the patient that you won't hurt them. 
  • Start with the patient's elbow to his/her side.
  • The trick is to adequately position the scapula before you start. Move the anteverted scapula posteriorly by having the patient sit up straight, puff out chest, pull shoulders back, and relax as much as possible in that position.
  • Go slow.
  • Points of maximal massage: Trapezius, Deltoid and Biceps muscle along mid-shaft of humerus.
  • Warn the patient that when the humerus starts to move, it may feel odd but try to not to resist it.










While I haven't used this technique before, I'll be sure to give it a try. Physiologically, the procedure makes sense.

Blogger is mobile-format friendly!


I have been toying with ways to make my blog more mobile-viewing friendly. It turns out that Google and Blogger are way ahead of me. They just launched a beta version where blog-owners can make their site mobile-friendly with a simple click of a button!

Now if only I knew how to build an app for my Paucis Verbis cards... Mobile technology is taking over the world.

Can cunnilingus cause intraabdominal free air?

Yes. There are several case reports.

Mechanism

Other causes of nonsurgical pneumoperitoneum include pneumothorax, spontaneous bacterial peritonitis, peritoneal dialysis, postpartum coitus, vaginal douching, postlaparatomy, postparacentesis.


Source

Cotton, B. et al. "Pneumoperitoneum from Orogenital Insufflation: An Incidental Finding Resulting in Nontherapeutic Celiotomy" J Trauma. 2005.

Article review: Professionalism in the ED through the eyes of medical students


Teaching professionalism in a formal curriculum is so much different than demonstrating professionalism in the Emergency Department. So much of what students and residents learn about professionalism are from observed behaviors of the attending physicians -- that is, the hidden curriculum.

In a qualitative study assessing medical student reflection essays during an EM clerkship, the authors (my friends Dr. Sally Santen and Dr. Robin Hemphill) found some startling results. The instructions to the medical students were to “think about an aspect of professionalism that has troubled you this month. Write a minimum of one half-page reflection describing what was concerning and how you might handle it.”

Results:
  • 61 of 150 reflection essays discussed professionalism themes.
  • Using a grounded theory approach, the authors first looked at the data and then created categorical themes. 

Analytic Domains
1. Demonstration of positive professional behavior
  • Demonstration of compassion and empathy
  • Tension between respecting diversity and respecting other core values
  • Balance between patient-centered care and effective care 
  • Commitment to ethical principles
2. Observation of unprofessional behavior 
  • Lack of compassion 
  • Not telling the truth 
  • Lack of teamwork 
  • Inappropriate medical care
3. Personal improvement and learning
  • Whether to speak up because they are subordinate in a hierarchy 
  • Plans for their own future personal professional behavior through reflection on observed professional and unprofessional behavior and their own behavior
The take-home point is that unprofessional behavior definitely occurs in the ED to varying degrees, and medical students are astute at identifying these. There were examples of lack of compassion, struggles in prescribing opiates to apparently drug-seeking patients, and not telling patients the truth.

As residents and faculty, we must maintain an open-mind and set high standards for professionalism. Even if you aren't being called out on it, learners are noticing. They just might not be vocalizing their concerns because of their role as "subordinates" in a hierarchy who depend on evaluations to secure a good grade on their rotation.

Especially with young, impressionable new medical students and interns in the ED soon to start in the new academic year, remember to lead by example.

Reference 
Santen SA, Hemphill RR. A Window on Professionalism in the Emergency Department Through Medical Student Narratives. Annals of emergency medicine. 2011 - in early press. PMID: 21624702
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For how many days after intraabdominal surgery can pneumoperitoneum be detected on plain x-ray?

3-4 days. Intraabdominal free air seen well beyond this should raise concern regarding a pathological process and not be attributed to the surgery.


Source

Brant, W. and Helms, C. Fundamentals of Diagnostic Radiology. 2007.

Paucis Verbis: Upper GI bleeding


Did you know that it takes at least 100 cc of blood in the upper GI tract to produce melena?

 We commonly see patients with upper gastrointestinal bleeding in the Emergency Department. They range from mild (a little hematemesis with normal vital signs and no comorbidities) to frighteningly ill (hypotensive and vomiting copious amounts of blood with a history of cirrhosis).

Since my favorite publication series, EM Clinics of North America, just came out with a bundle of GI-related review articles, I thought I would summarize the GI Bleeding article.

There are some interesting factoids:
  • A BUN-to-Creatinine ratio of ≥ 36 suggests an upper GI bleeding. I've picked up a few subtle GI bleeds in patients with altered mental status and hypotension based on these lab values.
  • We commonly give proton pump inhibitors (PPIs) and octreotide for severe upper GI bleeds with likely variceal bleeding, despite the fact that they are likely of no mortality benefit. Interestingly, the NNT website mentions that PPIs and octreotide don't reduce rebleeding rates or need for surgery either. While interesting, until our Medicine admitting teams and GI consultants are on board with this, I'm still going to be giving them. This just illustrates how hard it is to discontinue medications, which have been part of accepted practice, despite all of the literature (eg. high-dose steroids in spinal cord injuries).
  • Also useful are the dosing regimens for FFP and platelets, which I pulled from the Rosen and Roberts/Hedges textbooks. I often get asked how much to give. It's always nice to review the dosing protocol.


Reference
Kumar R, Mills AM. Gastrointestinal Bleeding. Emerg Med Clin N Amer. 2011; 29 (2), 239-52.
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A look back at the evolution of emergency medical care from the New England Journal of Medicine

"The ER, 50 Years On" is an interesting article published in the NEJM which takes a look at the evolution of emergency care over the past five decades.  It's amazing to see how things have changed in such a short period of time and makes me wonder what the emergency care landscape is going to look like years from now with the implementation of ACOs and health care reform.

A few interesting statistics:
  • Presently emergency care accounts for 3% of health care spending and employs 4% of US physicians yet handles 11% of outpatient visits, 28% of acute care visits and half of hospital admissions.
  • Presently the aggregate ER admission rate is 16.5%

    To read the NEJM, click here.

    Interesting blog: EM Literature of Note


    In the constant effort to try to stay current with key publications in Emergency Medicine, I came across this great blog site by Dr. Radecki called "EM Literature of Note", which I follow using Google Reader. It's worth checking it out. There are short, insightful summaries of recent papers.

    It's nice to see the community of EM bloggers grow. Welcome!


    Are antibiotics necessary for the treatment of a hordeolum?

    Usually not.  Hordeola which are caused by obstruction of the oil-producing meibomian glands tend to be self-limited and often resolve spontaneously within a week or perhaps earlier with the frequent application of warm compresses.

    Although there have been no clinical trials to prove benefit, topical antibiotics are recommended by some sources to - in theory - prevent secondary infection of other meibomian glands.  Systemic antibiotics should be administered for secondary cellulitis.


    Source

    Ferri: Ferri's Clinical Advisor 2011, 1st ed.

    Greenberg, M.  "Diagnosis: A Hordeolum"  Emergency Medicine News.  2002 June.

    Lindsley, K.  et al.  "Interventions for acute internal hordeolum."  Cochrane Database Syst Rev.  2010 Sept.

    Wald, ER.  "Periorbital and orbital infections"  Infect Dis Clin North Am.  2007 June.

    Yanoff & Duker: Ophthalmology, 3rd ed.

    Stick with the Herd?


    Knowing is not enough.  We must apply.
    -Johann Wolfgang von Goethe

    My daily commute to work takes me through the hills of western Pennsylvania.  It takes me 40 minutes to make the trip so I've really come to love podcast and audio based education.  Mel Herbert and the crew at EMRAP do a great job of putting on a quality show.  

    Recently, the crew recorded a debate between Mel and Billy Mallon about the Ottawa Aggressive Protocol for Atrial Fibrillation.   During his rant, Dr, Mallon makes some important criticisms of the protocol.  If he had stuck with his numbers, he would have made a convincing argument against the protocol.  But then, he blunders.  As an educator, he makes a statement to his residents and students that I see as irresponsible of an educator.

    It goes as follows:

    "My top 10 reasons for not doing this are: 1. Most don't.  And just as an idea in medicine and a concept: stay within the herd.  If you want to know what the problems are of not being in the herd, turn on the nature channel.  The gazelles that are not in the herd, are lion food.  Okay?  Stay with the herd!  The herd doesn't do this."

    Really?  REALLY?  An idea and concept?  That's the number 1 reason?  Do what everyone else does?  That sounds more like lawyer speak than physician speak.  Almost like when I overheard a fellow faculty member tell a resident to get ankle x-rays on a Ottawa negative patient "because this isn't Canada; Canadians don't get sued."

    The "go with the herd" mentality is a dangerous preposition in medicine.  Medical history is filled with vivid examples of how patients were harmed because the this mentality.  Virchow, the leading authority in his time, was particularly critical of Ignaz Semmelweis and his data to suggest that physicians could cut disease rates by simply washing their hands.  Who knows how many lives were lost due to the fact that physicians were "gentlemen" and felt that they didn't need to wash their hands.  160 years later, we're still dealing with the fallout.

    Why is it that interventions known to be effective take so long to put into practice.  Herd mentality.  If nobody else does it why should I?  There is an old joke in medicine that you don't want to be the first to do something.  But, you also don't want to be the last.  

    As educators, we have a responsibility to be second or third.  We need to be early adopters and try out new ways of taking care of patients especially when the literature shows some support.  We need to take what others have done and reproduce it, testing it with our learners and demonstrating that science constantly changes.  Even more, we need to measure our results and disseminate them with time.  Only then can we advance the care of our patients.

    Take the Ottawa Protocol, for example.  I've used it for 4 patients now with a 75% success rate.  To be fair, I haven't sent the patients home.  We don't have the most reliable outpatient followup.  That being said I've managed to admit patients to beds without the need to advanced monitoring since they didn't need vaso-active drips and have kept them off of the nastiest of nasty drugs, warfarin.  

    And that is only one example of a countless list.  The last 2 decades have shed light on the failure of medicine to adopt treatments that benefit society.  We have become far more capable of creating knowledge than using it.  Perhaps our fear of leaving the herd is partially responsible for this failure.  

    So lets change it.  Let's take the time to venture outward, leading the herd.  Let's generate knowledge and take time to test it, apply it, and teach it.  

    What of the risks?  Remember, when you lead the herd, you don't need to outrun the fastest lion, only the slowest gazelle.  You're never alone out there!

    Trick of the Trade: I need more lidocaine but I have sterile gloves on!


    How often has this happened to you --

    You are in the middle of a sterile procedure (chest tube, suturing, central venous line, lumbar puncture) and you realize that you need more lidocaine to provide better topical anesthesia. You don't have any more in your kit and you are alone in the room with the patient.

    "Uh, can someone help me out there?"

    Trick of the Trade #1:
    Keep extra lidocaine around for your painful, sterile procedures. 

    It's always when you don't have any will you need it. This is especially true for lumbar punctures. Why DO they package such a small volume of lidocaine in the kit? I typically use the pre-packaged lidocaine (usually only 3 cc) only as a backup vial and instead start the procedure with 10 cc of lidocaine, which I've gathered from outside the kit.

    Trick of the Trade #2:
    Tape a bottle of lidocaine (or bupivicaine) securely to a gurney edge or wall.

    If you don't have an assistant during your sterile procedure to hold the bottle up, create a setup so that you don't need an assistant. Before donning your sterile gloves, clean the top of the bottle with an alcohol wipe. Tilt the bottle downward so you can draw up the entire contents, if needed. Secure it on a gurney handle or even a wall. Be sure to securely tape the bottle, because sometimes the bottle slips out when you are either puncturing or withdrawing the needle from the bottle. You can slit a second piece of tape into a Y-shape formation to help secure the main taping job. Check out the photos.

    (side view of bottle on gurney handle)

    (top-down view of bottle on gurney handle)

    (side view of bottle on wall)

    Thanks to Dr. Kennedy Hall (UCSF-SFGH EM resident) for this tip.

    Does a patient shot with a lead bullet need to have it removed to avoid development of lead toxicity?

    Depends.

    Bullets lodged in joints should be removed because lead toxicity commonly develops as the bullet is solubilized by the acidic synovial fluid.  Bullets lodged in soft tissue however generally don't cause a problem as they are often walled off and not exposed to body fluids.  Nonetheless, if a lead bullet can be easily extracted it probably should be as there are case reports - albeit rare - of lead toxicity developing from  bullets left in non-joint spaces.


    Source

    Najibi, S.  et al.  "Management of Gunshot Wounds to the Joints"  Techniques in Orthopedics.  2006.

    Murdock, C. et al.  "Toxic Lead Levels Treated with 2,3-Dimercaptosuccinic Acid and Surgery"  Journal of Trauma-Injury Infection & Critical Care.  1999.

    Simple rules to make your Powerpoint talk rock

    I came across this great SlideShare set on some simple rules on slide design to make your Powerpoint-based talk great. Think of your favorite speakers (i.e. the Mattus and Weingarts) and inevitably part of the reason they are so great is because of their slide design.

    What is the cause of this chest x-ray opacity?

    click picture to enlarge

    CT of opacity.  Click picture to enlarge.










    Eventration of the diaphragm.  Caused by a thinned and weakened section of diaphragm - often congenital - permitting abdominal contents to bulge towards the thoracic cavity.  While eventration may cause respiratory distress in the newborn, adults are often asymptomatic.  The distinction between a localized eventration or a pathological mass is best made using CT or MRI.


    Source 

    Clinical Imaging: An Atlas of Differential Diagnosis.  5th ed.

    Adam: Grainger & Allison's Diagnostic Radiology, 5th ed.

    Article review: Inconvenient truths about effective teaching


    At the CDEM meeting during the SAEM national meeting this past week, the keynote speaker (Dr. Charles Hatem from Harvard) mentioned a great editorial article called "Inconvenient Truths About Effective Clinical Teaching."

    Here's a summary of the opinion article from Lancet:

    Clinician-educators are increasingly pressured to do more with less time and support (i.e. release from clinical responsibilities). Learners are the victims of this calculated move.

    The author talks about 8 habits to emulate as an educator, in the setting of these changing times. This is especially helpful to review as we are about to start a new academic year with fresh interns and medical students in the Emergency Department.

    1. Think out loud.
    • This lets learners understand our thought-processes as we apply population-based research to our individual patient. This translational process is often ambiguous with lots of gray areas. Understanding our clinical reasoning process, rather than just the end result of ordering particular tests or treatments, is an invaluable lesson for learners.
    • "If our profession is serious about lifelong learning, we must recognise that learning can’t happen without humility. Teachers who humbly think out loud help to show the way."
    2. Activate the learner.
    • "Experts agree that adult education is a tango: it takes two. The dance will fail, no matter how expert the teacher, if the learner is not actively, even passionately, engaged."
    • The most effective teachers use the democratic style, where learners are encouraged to think and act autonomously in real-time. The trick is to "activate" learner initiative while "protecting them from themselves" to avoid errors. 
    • With time pressures, it's easy to fall back to an autocratic approach (do what the teacher says). It's a constant struggle to employ a democratic style of teaching. In reality in the ED, we teach using a hybrid approach - sometimes autocratic, sometimes democratic.
    3. Listen smart.
    • Great patient care is all about taking a good history. Similarly, great clinical teaching is all about listening to the learner. What's his/her knowledge base, how is his/her clinical reasoning skills, and does s/he see the big picture?
    • Assessing a learner's presentations and discussions often requires that you (as the educator) independently talk to the patients to ensure that the facts are correct.
    4. Keep it simple.
    • Learners are constantly learning and processing various information when working clinically.  Boiling down complex medical issues to a few simple teaching points can be difficult for the educator, but it is most effective for the learner. 
    • Also, I find that you don't have to unload all of your knowledge on the learner. Pick 1-2 concise teaching points targeted to the level of the learner and focus on them.  
    5. Wear gloves.
    • This is critical. Put on gloves and go to the patient's bedside. Having a learner see your approach to bedside care, empathy, and communication are invaluable. We often take for granted the art of patient care and we can best teach it by demonstrating to others.
    6. Adapt enthusiastically.
    • Things rarely go exactly as planned on a shift. Instead of fearing surprises, use these unexpected occurrences (eg. patient clinical deterioriation, medication side effect) as teaching opportunities.
    7. Link learning to caring.
    • Teach about empathy and professionalism. 
    • Patient care involves actually caring about the individual patient. Patients are more than just about their disease. 
    • "Understand the patient's illness as well as their disease." 
    8. Kindle kindness.
    • Patients can sense genuine kindness and caring. Be a role model in how you talk with patients. There is a difference between indifferent politeness and genuine kindness.
    • Learners are more receptive to feedback when spoken with kindness, no matter how critical your comments are. For me, I picture myself as a coach in (rather than an evaluator of) their lifelong learning process, and frame their feedback accordingly. 

    Reference
    Reilly BM. Inconvenient truths about effective clinical teaching. Lancet. 2007; 370(9588): 705-11. PMID: 17720022
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    What is the treatment for the hip fracture seen in this x-ray?

    click picture to enlarge


    *

    *


    *

    *


    Impacted femoral neck fracture.  There is no consensus treatment.  Conservative non-operative treatment may lead to deconditioning secondary to prolonged activity restrictions and will fail up to 46% of the time secondary to displacement of the fracture fragments requiring delayed surgical fixation.  On the upside, a certain percentage of patients will do just fine avoiding the scalpel.


    Source 

    Cees, C. et al.  "High secondary displacement rate in the conservative treatment of impacted femoral neck fractures in 105 patients"  Arch Orthop Trauma Surg.  2005.

    Koval, K. and Zuckerman, J.  Handbook of Fractures. 2nd ed. 2002.

    Paucis Verbis: Lifetime attributable risk of cancer from CT

    How great would it be if you could give patients concrete numbers when you are talking about cancer risk and CT? Well, Dr. Hans Rosenberg (Univ of Ottawa)  has come up with just such a table.

    Using this table you can say that the risk is about "one in ..."


    Click on image above to enlarge.


    Reference: 
    Smith-Bindman R, et al. Arch Intern Med. 2008; 169(22):2078-88.
    Free access to PDF article: http://archinte.ama-assn.org/cgi/content/full/169/22/2078

    Social media in academia: Why do it?


    "Why would I want to participate in Twitter and social media?"

    This is a common question that I get from my fellow emergency physicians. They think that social media applications are for people who have nothing better to do than to read/write about trivial personal opinions.

    This year, the Society of General Internal Medicine (SGIM) held a workshop on "From Twitter to Tenure", hosted by well-known educators in the Twitter world:
    They each discussed how social media has played a positive role in their academic careers. They also posted summaries on their respective blogs:
    Bottom line: Social media develops a brand (or name) for yourself in the digital universe, forces you to constantly improve your writing, helps you build a network of potential collaborators, and opens up a world of opportunities for you.

    Given that 50 to 70 percent of cases of sudden cardiac arrest are secondary to myocardial infarction or pulmonary embolism should empiric thrombolysis be considered?

    Yes it should be considered as there are isolated case reports of dramatic success however, the majority of data does not demonstrate a systematic benefit.


    Source

    Pozner, C. "Therapies of uncertain benefit in basic and advanced cardiac life support" Up to Date. 2011 Jan.

    Rosiere, L. et al. "Fibrinolysis and Thrombectomy for Massive Pulmonary Embolus" American Journal of Therapeutics. 2011.

    The Academic Practice of Wilderness Medicine?



    The recent Society for Academic Emergency Medicine Annual Meeting just concluded after several fun and learning filled days in Boston.  I was fortunate to be able to attend and learn from the best and the brightest.

    One of the presentations that stands out in my mind was a panel discussion about the "Academic Practice of Wilderness Medicine."  Wilderness medicine probably got me into medicine to begin with.  In my teen years, I was a member of a Venture Crew and spent many hours learning to climb, kayak, and haul a pack.  Our leader was a former paramedic and encouraged several of us to pursue training as EMTs to be better prepared for handling emergencies in the outdoors.  Thus began my love of emergency and wilderness medicine.

    Being in a community academic site, I've always put wilderness medicine onto the back burner thinking that I didn't have the skills or resources enough to make it into a viable niche.  This presentation, given by Sanjay Gupta, N. Stuart Harris, and Michael Millin, was a nice summary of the growing field and has rekindled my interest in wilderness medicine.

    First, what is wilderness medicine?

    At its most basic, it is the practice of medicine in austere environments.  While generally thought to represent the out-of-doors, this can encompass military settings, event medicine, disasters, and other less than ideal settings.

    How do you start in wilderness medicine?  

    There are many ways to get started.  As an academic, we're always looking to cement our niche.  Probably the most basic way to do this is training.  Fellowships now exist in many places that are dedicated to wilderness medicine or wilderness medicine and EMS.  For those who have already graduated, there are any number of courses, seminars, and experiences available to build your expertise.  The Wilderness Medical Society even has a fellowship track for physicians to demonstrate a level of expertise within the field.

    But what makes it Academic?

    Here is where the presentation got interesting.  I've always thought of academic practice within this field as being research based; high altitude medicine, tropical diseases, etc.  Like many academic pursuits, there is so much more to practicing wilderness medicine.  You can, for example:


    • Become the faculty mentor for a wilderness medicine interest group
    • Teach at medical schools, residencies, or CME courses
    • Become a military, expedition, or event consultant
    • Serve as a medical director for a search and rescue team
    • Serve as a travel medicine consultant
    • Actually become a researcher
    • Participate in the leadership of Wilderness Medicine oriented committees, interest groups, or the WMS


    At SAEM, we became a fully fledged interest group at the meeting.  We even were able to head to the nearby quarry for an afternoon of learning the basics of high angle rescue.  The excitement on the participants faces as they took that first uncertain step into the air during their rappel was a priceless reminder of why I love teaching and emergency medicine.

    Having had my assumptions challenged and realizing that there are opportunities for developing an academic niche in wilderness medicine even at a community site, you can expect to see more on various topics related to Wilderness Medicine in the future!

    Clip to Evernote

    I would like to thank N. Stuart Harris for his leadership over the last year, his vision to start the interest group, and his willingness to share his rope, local crag, and experience with us this past week.

    Trick of the Trade: Fingertip injuries



    Fingertips can get injured in a variety of ways such as machetes, meat grinders, and broken glass. You name it, and we've probably seen it. Some don't actually need anything invasive done because the skin is basically just torn off. The wound just needs to be irrigated, explored, and then bandaged to allow for secondary wound closure.

    What do you do if the finger injury keeps oozing and the finger tip is too painful for the patient to apply firm pressure? Poking the finger with 2 needles to perform a digital block seems a bit overkill.


    Trick of the Trade:
    Soak the digit in 1% lidocaine with epinephrine for 5 minutes

    Pour 10-20 cc of 1% lidocaine with epinephrine into a small, sterile urine specimen cup. Have the patient dip his/her fingertip into the solution. The lidocaine will anesthetize the wound, and the epinephrine will help achieve hemostasis.

    After irrigation and better examination of the wound, you can now apply a topical hemostatic pad (eg. Surgicel, Gelfoam) over it and wrap the finger with tubular gauze.

    Thanks to Dr. Mak Moayedi (Univ of Maryland) for this great trick!

    What is the treatment for intracranial or serious systemic bleeding after thrombolytic therapy with tPA?

    Cryoprecipitate and platelets.


    Source

    Wechsler, L. "Intravenous Thrombolytic Therapy for Acute Ischemic Stroke" N Engl J Med. 2011 June.

    Find the closest ER = findER app



    One of the cool things about having a blog is now people come to me with news. That's how I learned about Mass General's Emergency Medicine Network (EMNet) and their new mobile app called "findER". It makes clever use of the mobile phone's GPS capability and internet accessibility.

    Here's the info that they provided:

    The app launched for the iPhone in June 2010. Due to popular demand, we have recently introduced the app on Blackberry and Android platforms.

    Through our studies, we have developed the most comprehensive, accurate emergency room (ER) database in the country. This free app uses that database of nearly 5,000 U.S. ERs to benefit individuals in an emergency situation. With one click, findER will get its users to the closest ER in the event of a health emergency. We think that the app is a must-have addition to anyone’s phone, especially when traveling with young ones and family members with chronic health problems during the upcoming summer months.


    SAEM National Meeting a success!


    The national SAEM meeting in Boston just concluded and was a success. As part of the SAEM Social Media Committee, I was encouraged to see how many people were tweeting events from the meeting. Check out the tweets with the #SAEM11 hashtag.

    To view beyond the most recent 100 tweets, you can view here.


    3rd Malaysian International MMA Medical Students Conference on Trauma

    The 3rd Malaysian International MMA Medical Students conference held at Melaka-Manipal college has just concluded (2nd - 5th June 2011). I must say that it was a huge success given the limited resources they have, especially since the committee members themselves are busy medical students, many of whom are clinical students. I wish that more medical students from Universiti Sains Malaysia could

    Paucis Verbis: Pulmonary Embolism Clinical Prediction Rules


    "Should I get a D-Dimer test or CT chest angiogram on my patient with atypical chest pain to rule-out a pulmonary embolism?" This is a common question asked by emergency physicians on a routine basis.

    Here are 3 clinical prediction rules: PERC, Wells, and Simplified Geneva Score. Personally, I've never used the Geneva Score, but it's worth looking at.

    NOTE: These rules should be used with caution, because none of these scoring protocols are perfect. For instance, in a very recent publication in the Journal of Thrombosis and Haemostasis, the authors found that the PERC rule does not actually safely exclude PEs. Big bummer for us clinicians.




    Thanks to Dr. Kit Tainter (Mount Sinai PGY-4 EM resident) for coming up with the idea for this card!

    Internet CME: EMedHome.com


    Two weeks before renewing your license, you realize that you're short 7 CME credits. Uh-oh...what to do now? Unfortunately, not enough time to go to a conference. Reading always gets boring after a while. Lie on your renewal application (NOT!)? If only there was a one-stop method of getting a variety of CME to keep you interested.



    As mentioned in multiple posts, the internet has forever changed medical education. In today's post, I would like to focus on one specific website: EMedHome.com.

    EMedHome was created in February 2000 by Rick Nunez, MD, an emergency physician. It is an accredited CME provider by ACCME. The website is operated independently without third-party support, thus never any influence from drug/device manufacturers. It hosts an impressive editorial board which includes Peter Rosen, Joe Lex, Laurence Raney, Selim Suner, William Brady and Rob Rogers.

    Some of it's features include:
    • On-Line EM Lectures - Lectures from some of the best conferences in EM (AAEM Scientific Assembly, state ACEP conferences, Giant Steps in EM, Mediterranean EM Congress and more). Most include the Powerpoint slides and audio, if not actual video of the speaker. MP3 is also an option for those that prefer to listen in the car or on a MP3 player. The lectures usually offer 0.5-1 CME credits.
    • EMCast - A monthly podcast hosted by the talented Amal Mattu along with guest commentaries. Each monthly podcast offers 1.5 CME credits.
    • CME Feature Article - Offered on a bimonthly basis for those that prefer a traditional reading activity. Each article offers 2 CME credits. They cover a variety of high-yield EM topics as well as Joe Lex's annual "Some Drugs from 20** That Might Change Your Practice".
    • LLSA CME Program - Provides access to the yearly articles, outlines and up to 35 CME credits.
    • Clinical Case - Every other week, an interesting clinical case is offered, along with pertinent education points.
    • Clinical Pearl - Weekly pearls are offered which usually focus on the most cutting edge EM topics.
    • Question of the Day - Test your EM knowledge with these daily quizzes.
    • And much more!
    This is all offered for $99/year. $99 for over 70 CME credits annually! I've utilized EMedHome since starting my career and it's been one of the best investments in my education. The Clinical Case, Clinical Pearl and Question of the Day can also be sent directly to your email without having to log-on to the site.

    There is also a special ACEP-EMedHome.com section which offers additional content such as lectures from ACEP Scientific Assembly. This section is available only to ACEP members.

    Disclosure: No financial interests in EMedHome. I'm just a satisfied subscriber.

    Tricks of the Trade: Tea bags to the rescue



    I have heard of using tea bags under your eyes to reduce puffiness, but to combat odors in the ED?

    In my growing list of "Tricks of the Trade" tips for protecting your olfactory nerves (Antacid booties for toxic sock syndrome, aerosolized orange juice, abscess drainage using suction), I got a clinical gem from Dr. James Juarez (Rogue Valley Medical Center in Ashland, OR) after my recent Tricks of the Trade talk at High Risk EM in San Francisco.





    Trick of the Trade:
    Wear 2 face masks and insert a fresh, dry tea bag in between.

    In close proximity to your nose, the tea bag's pleasant aroma can help fight the variety of noxious odors which you might encounter in the ED.

    Now the questions that I have are:
    • Which flavor is best? Is green tea better than Egyptian Chamomile?
    • How MANY bags will I need for various malodorous conditions? I foresee an odor scale, similar to the pain scale: "How smelly is it, on a scale of 1 to 10 tea bags?"
    I suppose I'll have to try and discover for myself. Anyone else use this trick? Thanks, James!