Poll: How would manage a metacarpal fracture in the ED?

I am in the process of creating a PV card on metacarpal fractures, divided into anatomical areas (base, shaft, neck, head), and am realizing that the EM and orthopedic literature don't quite agree. Actually they are quite vague on whether reductions should occur in the ED vs orthopedics clinic in the next few days.

• Do you need to close-reduce all angulated fractures in the ED, which are outside of "acceptable" angulations?
• What exactly are "acceptable" angulations? Some sources say that angulations of 10, 20, 30, and 40 degrees are acceptable for MC neck fractures and only 10, 10, 20, and 20 degrees are acceptable for MC shaft fractures. These numbers, though, vary from reference to reference.

The only consistent thing I've read is that rotational angulation (where not all the fingers point to the patient's scaphoid bone) requires reduction in the ED because of the concern for functional impairment.

School of thought #1:
Reduce all angulated fractures. Heck, it's bent. Straighten it.

School of thought #2: 
Leave all fractures alone. As many of 50% of fractures, especially unstable ones, will lose their realigned position when the patient is seen at the outpatient orthopedic visit. Just splint it and follow-up.

School of thought #3: 
I reduce some but not all angulated fractures.

Would love to hear the variations in people's practice. Feel free to use the Comments section of the blog to explain.

Poll: Is anyone using the Paucis Verbis cards?

Feedback is essential for continued growth and improvement in any longitudinal project that you work on.

Thus annually, I conduct a poll to see if I can improve anything on the blog. This year, I wanted to focus on the Paucis Verbis pocket cards. There are over 100 cards now, which are each based on recent peer-reviewed publications. I try to make them as practical as possible with the goal of improving evidence-based practice at the bedside.

I personally use these cards almost on every shift to help teach students and residents as well as a clinical reference tool. Really, who can remember ALL of the Canadian C-Spine Rules criteria or the PECARN criteria for head CT imaging in pediatric patients!?

Currently, one can access PV cards by:

• Reading from the blog website
• Manually downloading each PDF or DOC file
• Subscribing to my Dropbox PV folder
• Subscribing to my Evernote PV notebook

Because I am not tech-savvy enough to track downloads, and Dropbox/Evernote doesn't track subscriptions or usage, I have no idea if I am the ONLY person using these cards. If no one is using them, I may have to rethink what might be useful to the blog readership. I'm totally open to new ideas and change.

In that spirit, would you be kind enough to fill out a very brief, anonymous survey? Thank you so much for your time.

Click to read the already submitted responses.

Survey: Why do you use Twitter?

I recently got a comment on the blog asking why people need to use Twitter, if they're already following blogs. I thought I would open this up to the blogosphere.

I personally use my Twitter account (@M_Lin) for a variety of reasons:

• I tweet the link to my blog whenever there is a new post (I just tweeted a link to this post!)
• Scan quick, real-time information from clinicians I trust
• Know "what's hot" in EM, medical education, and education technologies
• Learn of new blogs and websites which I didn't know about
• Quickly check tweets on-the-fly on my iPhone during downtimes
• Make new friends who I then meet in person at EM conferences!

Please comment below and include your Twitter name, if possible.  I'd love to know why (or why you don't) use Twitter.

Poll: YOU are on the residency selection committee. What would YOU do?

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.

Poll: YOU are the clerkship director - What would YOU do?

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.

Brief survey: Need your help with my promotions!

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. 



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

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

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



Here is one for starters:



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



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







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

First annual Medical Apps Awards: Vote now

The polls for the first annual Medical Apps Awards is now open. Voting closes April 21, 2011 @ 12:00 AM EST.

• General instructions (you can win various prizes)
• Go directly to the polls

There are 3 categories that you can vote on:


1. Best Medical App for Healthcare Professionals

• MediBabble - a medical translation tool
• Doximity - a professional networking tool
• Medscape - comprehensive guide to drugs, interactions, diseases, & procedures
• Epocrates - comprehensive guide to drugs, interactions, identifying pills, & calculators
• DrChrono - the first EMR for the ipad

2. Best Medical App for Patients

• iHealth BPM w/ cuff - the first medical app to take your blood pressure & keep track of it
• Asthma Maze - know which food additives & cosmetic ingredients can trigger an asthma attack
• Mayo Clinic Diabetes Type 2 Wellness Solutions - comprehensive guide to diabetes
• Free RX iCard - get discounts on prescription drugs at participating pharmacies, easy locater
• Calorie Tracker by Livestrong - keep track of your daily calories and weight loss progress

3. Most Innovative Medical App

• Airstrip - monitor your patient's vitals, waveforms, labs, I/Os, meds, & allergies from home
• Webicina - a comprehensive online medical resource for both patients & healthcare folks
• Fooducate - scan any barcode in the grocery store to instantly see product health highlights
• PocketCPR w/cradle - real-time feedback so that anyone can do CPR correctly
• Google Translate - speak into your phone and it will speak out the translation

I thought I would mention this since Medibabble was created by recent graduates from the UCSF School of Medicine. It's a creative, well thought-out, free medical translation app. I had highlighted the app back in Feb 2011 and deserves to be on the list of impressive apps.

The downside of voting is that you are required to enter your email and snail-mail address in case you win the prize. Good luck to all the nominees!

I do not have any financial ties with any of these apps.

Poll: Which handheld drug prescribing app do you use?

Well I finally took the leap and am primarily relying on my iPhone to look up medication doses, which I don't know off the top of my head. Gone are the days of purchasing Tarascon's pocket Pharmacopoeia every few years or so.

I still haven't settled on which I like more. Both are free. Both are available on multiple platforms, including iOS, Blackberry, and Android. Both have some unique features which I find useful.

Common strengths for both apps:

• They're free!
• Easy to find drug you are looking for. Epocrates has a Search screen as the home page. Micromedex has a Search screen and alphabetical list of medications as the home page.
• Dosing adjustments based on renal and hepatic function
• Adult and pediatric dosing recommendations
• Safety information with preganancy and lactation

Unique strengths of the apps: 

Micromedex: 

• Includes toxicology information for all the medications (what to do in case of an overdose) 
• I have heard that this Thomson Reuters app has been more peer-reviewed and accepted as a very reliable resource, especially for pediatric dosing.
• Free from obvious advertisements (which is sometimes seen in Epocrates via the Doc Alerts)

Epocrates: 

• Has pricing information
• Allows user to identify unknown pill based on pill characteristics (color, shape, etc)
• Ability for you to take notes on the app

They both will likely answer 99% of what you are looking for from a drug-prescribing perspective. So, which do you prefer and why?

Poll: What other specialties were you considering?

I can not imagine working in any other specialty except Emergency Medicine. During medical school, however, I was torn between various specialties. These included Vascular Surgery (had an inspiring attending on-service and the VA patients were hilarious) and Interventional Radiology. Fortunately, I saw the light.

I am curious, as a medical student, what specialties were you considering before deciding on EM? It would be interesting to see if there were a trend.

Poll: How do you recover from a night shift?

There are so many amazing things that we get to see and do as emergency physicians.

• We see sick, undifferentiated patients who need our help acutely.
• We have cool toys, such as ultrasounds.
• We get to do great procedures.
• We work on a shift-based schedule.
• We work in team-based fashion with fun nurses, technicians, and staff.
  

However, one major down side is that almost all of us work some night shifts.

Question for the readers:
Let's say you just finished your shift at 6 am. Your next shift is at 6 am the next day. How do you recover from your night shift?

For me, I try to work 3-4 night shifts in a row and then try to stay up as late as possible after the last shift. Usually, I pass out at 7 pm and wake up at 5 am the next day. I'm good to go.

Other options I've heard of include:

• use of medications such as ambien
• short nap mid-day after a night shift and then getting 6 hours of sleep at night
• incorporation of rigorous exercise after your night shift

I'm curious. What do you do?

Poll: Evaluation anonymity

As educators, we are constantly being asked to complete evaluation forms for medical students and residents. Most are in the form of formative evaluations. That means that you are giving the learner frequent feedback (like a coach) so that they can do better in the immediate future. This is in contrast to summative evaluations, which are conducted for the purposes of "grading" the learner.

More and more institutions are moving towards a daily post-shift evaluation of medical students and residents rotating in the Emergency Department. This is often done online. There are pros and cons for having the evaluations be anonymous.

PROS (for anonymity)

• Faculty may avoid giving negative feedback to learners for fear of awkward interactions on future ED shifts.With anonymous evaluations, faculty may feel more comfortable giving constructive criticism.
  

• If faculty avoid giving constructive criticisms (or at least very watered down) in non-anonymous evaluations, problem issues may go undetected longer because no one comments on them.

CONS (against anonymity)

• Medical trainees are adult learners and should be adult enough to hear direct feedback.
• Knowing who the evaluation is from allows for more direct discussion of specific cases or scenarios.

What do you think should be done?

Comments are welcome to explain your reasoning from the perspective of a learner or educator.

What's in your pocket on an ED shift?

I am always curious about what people carry in their scrubs and lab coat pockets. Often you can identify residents based on what they are carrying or wearing. Stereotypically, I find the following:

• Long reflex hammer jutting way out of the lab coat pocket - Neurology
  
• Plaster smears on their scrub tops and bottoms - Orthopedics
  
• Fluffy animal on their stethoscope and/or lab coat - Pediatrics
  
• LMP wheel - Obstetrics/Gynecology
• Small textbook in lab coat pocket - a medical student

What do I carry?
Starting from at the upper left of the photo and moving clockwise:

• Electronic stethoscope
• iPhone (I mainly use the visual acuity chart app and calculator)
• Intake pad to document ED referrals from primary care physicians
• 3-4 pre-printed Vicodin prescriptions. Because we prescribe these like crazy, I often write a few up just before starting my shift to save time.
• Small bottle of unused 1% lidocaine
• Bright LED flaslight
  
• LED flashlight holster, which I hook onto my scrub pants
• Pen - which I quickly lose within 2 hours of my shift
  
• My "peripheral brain" on color index cards with various algorithms, literature guidelines, diagrams, and facts to help me teach residents and students on shift. The top card currently displays the acetaminophen metabolism pathway and facts about acetaminophen toxicity.
  
• Sanford Guide to antimicrobial therapy
• Pocket Pharmacopoeia
• Trauma shears (not shown because I just realized that I'm still wearing them - I just got off shift!)
  

Question for you:
What do you put in your pockets for an ED shift?

Who are you? A blog reader census

Well, it is 142 posts later, and I still love writing this blog. To follow one of the cardinal rules in teaching, I would like to get a sense of knowing who my audience is. That way I can tailor some of my posts to the readership. If you have a second, fill out these two polls. Thanks!