SimWars: A "warring tigers" competition

SimWars

You’ve seen this word on the agenda at the most recent Emergency Medicine conference that you attended. It sounded interesting... but you ended up going to a happy hour and missed out on the event. And so you are left with the burning question, what is SimWars?

I have now heard Dr. Haru Okuda (Director of VA SIMLEARN) introduce SimWars a few times at the start of competitions at conferences. He usually has a photo of two cute little kittens with great big sweet eyes juxtaposed with a photo of two warring tigers fighting each other. He uses this comedic relief to illustrate the difference between a standard simulation session and SimWars competition. 

A hilarious video that playfully shows the competitive nature of the competition can be seen in this clip for the upcoming Social Medical and Critical Care (SMACC) Conference in Sydney on March 11-13, 2013.  

The History of SimWars
Creators, Drs. Andy Godwin (EM Chair of Univ of Florida-Jacksonville), Haru Okuda and Scott Weingart (Mt. Sinai-NY and Emcrit.org) originally developed SimWars in response to an observed lack of urgency in response to simulated cases used in education. They watched their residents wait for the inevitable bomb to drop before actively managing the patient and thought perhaps they could build some healthy stress into the scenarios. 

In addition to providing an avenue for large group education at local, national and international conferences, SimWars allows a unique opportunity to observe the differences in how different training programs address similar situations. SimWars is also a way to showcase the utility of simulation training to more “sim-naïve” educators. It’s definitely an exciting introduction to those new to simulation.

SimWars presence at major meetings

SimWars were held at the recent SAEM, ACEP, International Meeting on Simulation in Healthcare (IMSH), and the Canadian Simulation Summit conferences. This allowed the demonstration of interdisciplinary teamwork and communication, which was the focus of such events as IMSH and the Canadian Simulation Summit. Dr. Lisa Jacobson (University of Florida-Jacksonville) has joined the SimWars team and coordinates much of the ground work.

Personal perspective

I have participated myself as a confederate and case writer.  Confederates, or “actors,” play an important role. We often are the source of important information, whether it be subtle exam findings or significant history, but just as in actual care environments, these details may be difficult to glean amidst obstructive/entertaining personalities or surrounding chaos. It is the confederates’ role to provide a balance between chaos and flow, helping to move the case quickly forward to adhere to the short time periods necessary for a competition. 

Case writing is also a fun challenge. We get to brainstorm all the possible ways a team may respond to the case and how to create manageable barriers for them to overcome. You don’t want the case to be too easy, nor do you want the case to be impossible. Most importantly there should be specific educational goals. Watch out for those twists!

Bottom line

Ultimately, I have found SimWars  to be an unique educational platform, which balances the entertaining and the challenging. There are plenty of opportunities to learn and educate, whether you are a judge, a sim team member, confederate, or case writer.

Join me at the next SimWars competition in Orlando, FL at the IMSH Simulation conference (Jan 26-30, 2013)!

Special thanks to Dr. Lisa Jacobson for her help and contribution to this blog write up.

The secret to patient presentations

So there’s a patient, and umm...  they are in the hallway, they came to the ED today for breathing problems, I mean dyspnea.  They also don’t speak any English.  So, uh the respiratory rate is normal, and they had a blood clot, er... I mean PE, in the past, but not on coumadin anymore.  Shoot, I forgot to tell you my exam...they had pitting edema for 3 months.  By the way, the labs came back on that other anemic patient in the other hallway, and they are really anemic...

Sounds familiar? Perhaps a medical student or intern-level presentation of a patient in the ED?  Imagine working in a hectic ED while listening to this chaotic presentation. 

What's the secret to presenting patients?

We, as attendings or senior residents, often assume that increasing knowledge will lead to improved presentations, and so focus on broadening their medical knowledge. That's only part of the solution.

What's the other part? Polishing the trainee's public speaking skills.  This is just like recommending to a lecturer that to improve their lectures, they should develop public speaking skills. In this case, the lecturer (trainee) is lecturing to an audience of one (attending).

Think of presentations as mini-impromptu speeches.  

Important qualities in public speaking:

• Lack of fillers (um, so, uh, really, like)
• Knowledge of content
• Brevity
• Organized structure
• Eye contact
• Subject matter of pertinence to the audience
• Practice (go over the presentation in your head once before giving it)

As a senior resident or attending taking patient presentations, imagine a presentation that is succinct (less than 1-2 minutes), where the trainee avoids filler words, with an organized history, physical, assessment, and plan.  Imagine a presentation that does not deviate but remains true to the topic and tells a coherent story.  This type of presentation would almost be like a gentle relief in an over-stimulated ED environment.

Just as how you probably would not interrupt a good public speaker in the middle of his/her speech,  you should hold your questions until the end of their presentation. Remember this, and try to allow the trainees to finish speaking.  It may help them to keep their train of thought and structure.

For the senior resident or attending:

• I challenge you to consider these aspects of public speaking the next time you listen to a patient presentation from a student or resident. See if you can make recommendations to improve his/her presentation style as well as the content.

For the trainee:

• Work on being a better public speaker. 
• As a side note, I was a part of Toastmasters International which is a nonprofit public speaking organization while in college.  Although I am no longer with the organization, I credit them with significantly improving my confidence and public speaking skills in both prepared and impromptu styles. Plus it was a lot of fun!  This is definitely something to consider if you are looking for a way to improve your public speaking skills.

Losing faith in "evidence-based medicine": Etomidate and sepsis

In an era where evidence-based medicine is the goal, it is vitally important for practitioners to understand how to prioritize and interpret the onslaught of data coming at us. 

This fact was driven home for me with a recent publication. Several weeks ago an article was published in Critical Care Medicine entitled "Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis."

The point of this post is not to debate if etomidate should be used to intubate septic patients. Etomidate very well may kill people with sepsis. I just don't know from the data currently available. Using this meta-analysis as an example, the goal is to point out two important areas where we could stand to sharpen our literature evaluation skills.

Point #1: Choose (and interpret) your titles wisely.

It is an overwhelming task to skim through several journals' Table of Contents each month. In a specialty such as Emergency Medicine, many relevant articles appear in non-EM journals making it even more challenging. It's tempting to think we know what an article concluded, based solely on its title.

This point particularly applies to those who publish. But readers also should use extreme caution if only reading titles and abstracts. Given that the last several articles on this topic found that etomidate did not increase mortality when given as an induction agent to septic patients, I was quite surprised to see this bold title declaring etomidate is associated with mortality. We're all so busy that it would be very easy to simply see this title and assume it to be true, without ever reading the article. That is very dangerous medicine, in my opinion. And, this principle extends far beyond this one meta-analysis. 

I've already seen etomidate avoided in a hypotensive, septic patient based on this article. I've also heard colleagues giving a quick summary of the article to students and residents saying this article "confirms what we already knew." What?!? When did we definitively "know" this? I still can't believe a highly regarded journal such as Critical Care Medicine would allow this article to be published with this title.

Point #2: The meta-analysis is not the end-all-be-all of publications.

We've all sat through some sort of literature evaluation class back in school. When the meta-analysis was described to me as a student, I remember thinking how awesome it was. Let me get this straight... people way smarter than me are going to take all of the articles published on a given topic, perform some fancy (way over my head) statistics, and give us an evidence-based conclusion? Sign me up. Coming out of pharmacy school, I pretty much thought meta-analyses were the cream of the crop when it came to the published literature. How wrong I was.

I shouldn't have to go back and analyze each of the articles the authors used, but that is exactly what I did in this case. Here is what I found:

With regard to mortality, 5 trials were included. The 4 smaller ones mostly demonstrated that etomidate did not increase mortality compared to other agents. However, the one larger trial encompassing 499 of the 865 total patients (58%) did show an increase in mortality. It was published by Cuthbertson, et al in Intensive Care Medicine in 2009.

Let's take a closer look at this ICM study. 

It was such a large contributor to the meta-analysis outcome, it seems important to understand what that trial was all about. Despite the authors calling it an a-priori sub study of the CORTICUS trial, it was actually a post-hoc analysis looking at etomidate's association with mortality. You can read the two published commentaries to the Cuthbertson study by Pallin and Andrade, which each highlight several major issues with the data in this trial. 

The bottom line is that the trial by Cuthbertson was highly flawed and really doesn't give us any insight as to etomidate's contribution to mortality. In fact, one of the biggest critiques was that physicians in the CORTICUS trial were instructed to avoid etomidate due to its propensity to suppress cortisol production. So, when physicians did use it, there was likely a reason for it (ie, the patient was hemodynamically unstable and they didn't have many other good induction agent options). Therefore, etomidate was probably given to the sicker patients already more likely to die from the start. 

If you dig even deeper, you'll find that the Cuthbertson group used two logistical regression models. One showed a nonsignificant increase in mortality while the other showed a significant increase. Of course the statistically significant one was reported in the abstract. The bottom line is that if you use bad data to construct a meta-analysis, you'll end up with a bad meta-analysis.

So where does this leave us?

In part, it means we have to remain as skeptical as ever when reading published articles. We already know titles and abstracts don't give the full picture. Taking into account reporting biases, funding sources, and even authors' personal/professional agendas, it seems we can't always rely on the peer-review process to uphold the highest standards of integrity. The best journals out there aren't immune. One reason I love Free Open Access Meducation (FOAMed) is that the peer-review process is instant and no holds barred. If you post something that is inaccurate or controversial on Twitter or a medical education blog, you will get called out on it. The best part is that the ensuing conversations inevitably lead to knowledge sharing and learning. Isn't that what research is supposed to be about after all?

Dr. Joe Lex said it best on Twitter:

I couldn't agree more.



References:

1. Chan CM, et al. Etomidate is associated with mortality and adrenal insufficiency: A meta-analysis. Crit Care Med 2012;40(11):2945-53. [PMID 22971586]
2. Cuthbertson BH, et al. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Intensive Care Med 2009;35(11):1868-76. [PMID 19652948]
3. Pallin DJ, Walls RM. The safety of single-dose etomidate. Intensive Care Med 2010;36(7):1268-70. [PMIS 20405278]
4. Andrade FM. Is etomidate really that bad in septic patients? Intensive Care Med 2010;36(7):1266-70. [PMID 20405279]

New blog section on Medical Education by Dr. Nikita Joshi

Introduction of a new section on Medical Education

Sir William Osler, renowned physician and believer in bedside medical education, once stated:

“I desire no other epitaph…than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.”

And with this quotation I would like to introduce a new segment to Academic Life in Emergency Medicine.  One of the most important job descriptions we have as physicians is to be a clinical instructor… while simultaneously running cardiac arrest codes, managing agitated altered mental status patients, and avoiding documentation errors.

It is a tremendous task, especially considering the multitasking, organizational, and time management skills that are already demanded of us.  However, the ED is the perfect setting to provide medical education at levels including medical students, residents, and junior faculty as well.

With this blog, I hope to discuss issues such as:

• Bedside teaching tips
• Relevant medical educational theories
• Small and large group lecturing tips
• Effective use of technology, such as iPads in providing medical education.  

This section will ideally provide a forum for discussion as a place to share ideas, concepts, and successes from other readers. Ultimately, I hope to excite passion for medical education and to provide practical ideas for teaching.

Additional reading:

• "Oslerisms" from Life in the Fast Lane medical education blog
• "William Osler - Biography" from Medical Archives at Johns Hopkins

Do you know your resuscitation room?

When I was in medical school doing my critical care elective in EM, I remember seeing the interns preparing tubes and IVs before their shifts started. Since then it was instilled in me that coming early to the shift was essential to make sure that at least your resuscitation room was adequately set up for any major emergency coming through. With the help of a few friends, I made up a list of the equipment that should be present and working appropriately in your resuscitation room.

Not only should you have to have the appropriate equipment, but you should also make sure they are working appropriately. You may be surprised at what is missing or non-functional. The most important part of our job is to be prepared: 

“Hope for the best, anticipate the worst.”

I tried looking for a proper definition and a list out there in the “interweb” that I could modify, but didn’t find one. I would recommend you get to know all of your nurses by name (especially the charge nurses) and have a good working relationship with them. It is essential, they are an integral part of the team.

1. Oxygen

• There should be two outlets: make sure there are two and they work appropriately with appropriate tubing. Have the bag valve mask ready 

2. Pulse ox detector

3. The CO2 detector should be ready and functional (contributed by @AndyNeill)

4. Suction with canister, yankauers, and tubing 

5. Intubation kit and airway cart: lots of stuff in this cart

• Endotracheal tube introducer (Bougie)
• Working laryngoscope (make sure light bulb is working, straight and curve blades) 
• Tube sizes 
• BVM, OPA, NPA (contributed by @jcillo)

6. Video laryngoscope with appropriate stylet, working light, plugged, and tongue blade

7. Cardiac monitor

• Blood pressure cuff: make sure you have different sizes 
• Pulse oximetry: know the different kinds 
• ECG leads: cables and stickers

8. Gurney

• You want a working gurney where you can lift the head of the bed at least 45 degrees 

9. Central line kit: different sizes, triple lumens, trauma infusers

10. Code Cart with their appropriate drugs

• This is usually checked by the charge nurse, just make sure it’s in every resus room

11. Blood products (in the oven)

• What’s the blood bank’s extension number? 

12. Chest tubes

• Chest drainage systems

13. Ultrasound

• Plugged, clean machine and probes, probe covers.

14. Ventilator Machine

• What’s the respiratory therapist’s extension number? 
• Know your ventilator machine.

15. Intravenous pumps

• Nurses are usually in charge of these, but make sure they are in the room.

16. Blood draw equipment

• Tubes, tourniquets,  syringes, butterflies, intravenous catheters.

17. Foley catheters

18. Naso/Orogastric tubes

19. Childbirth equipment

20. Naso/Orogastric tubes

21. Childbirth equipment and warmer

22. Ophthalmoscope

23. Broselow tape

24. Telephone and phone/pager contact list (contributed by Matthew Mac Partlin)

25. Routes and distance/time to key locations (Radiology, OT, ICU, Blood bank)  (contributed by Matthew Mac Partlin) 

I hope this serves as a guide to make sure your resuscitation room is working appropriately.

RIP: Ode to my textbooks

If you were to take a look at my bookcases, you would classify me as a book hoarder. Yes, it’s true I have been collecting book. Some have been with me since college. Books have so much information, and I have always felt a bit paranoid about throwing them away and then not having them for a critical piece of information that I need.

My collection includes books on biochemistry, physiology, anatomy, and others. To be honest, I really have not used them as much as I have used my online sources, and that’s not because I have memorized everything in these books. We are told during college and medical school that we must memorize everything. With the explosion of information, however, it is more practical to know the specific question for which you need the answer for and have reliable sources. The goal is to memorize as much as possible, but also know how to find information in the most efficient manner.

Nowadays, books are already in the internet; MDconsult and AccessMedicine are two of my main sources. They contain all the textbooks I would ever need to answer my questions. There is also UpToDate which contains tons of current articles as well. I have used these sources for years, but getting rid of my books never really crossed my mind. I’ve become quite comfortable with reading texts online, downloading pdf files, and directly taking notes on the actual files. I also use Evernote to curate interesting articles (see Academic Life in EM's shared Evernote notebook link).

The Textbook is Dead Debate from Andy Neill on Vimeo.

Recently, Dr. Mike Cadogan (@sandnsurf), from Life in the Fast Lane, participated in a debate stating that physical textbooks are essentially dead. I watched this video and stared back at my bookcases. I realized that I should not fear not having the textbooks. More than enough textbooks are online. The internet allows me to go almost anywhere and still have access to these digital texts.

Currently, medical school, residency, and CME curricula are also moving online. This includes online lectures, podcasts, and videos. Respected physicians are even demonstrating procedures online. Learning is just not the same as it used to be. It's no longer about sitting in a lecture hall or reading a heavy textbook for hours. Now we can easily learn and collaborate with people worldwide in real-time and asynchronously through such social media platforms as Twitter or Google+.

 

This post is an ode to the physical being of my textbooks. They have now passed on to a better space (cyberspace), and I have learned to live without them. They taught me a lot, we were together through the good and bad. They used to accompany me to the anatomy lab, spend long sleepless nights together, and sometimes I would even wake up with my forehead against them.

So, I agree with Mike 100%. Textbooks ARE dead.

Farewell my friends, spread your hard and softcovers in book-heaven.

Javier Benítez, M.D.
@jvrbntz

gplus.to/javierbenitezmd

Area of Distinction resident project: Health disparities and ED closures in California

Here is another slide set from our residency program's Area of Distinction presentation day.


Dr. Hemal Kanzaria presented his project on Health Disparities in California, specifically focusing on ED closures. The data was pulled from various state and national datasets. Of the 7.2% (29 of 401) of ED closures in California during 1998-2008, it seems that for-profit hospitals with a high proportion of non-White and MediCal patients are more at risk. Fascinating data.

Areas of Distinction resident project: Injuries in Golden Gate parks

Last week, I had the pleasure of listening to our graduating EM residents' Area of Distinction (AOD) project presentations. I was actually quite blown away be the caliber, sophistication, and variety of projects. I thought I'd share a few on the blog.

Here is the first one by Dr. Jake Miss on "Injury patterns and incidence in the Golden Gate National Recreation Area (GGNRA) during 2005-2009" his Wilderness Medicine AOD.

I am still wondering what a "foreign body" injury is from Table 2. Apparently there were two instances of this during the study period.

UCSF-SFGH Emergency Medicine residency program

Modern EM: Case #4 - Palpitations



Caution: this caterpillar has been known to cause sudden cardiac death



Case # 4: Palpitations

A 25 year old woman presents with palpitations, sweating, and shortness of breath since this morning. 6 days ago she had syncopized, was shocked out of V-tach by EMS, and eventually had a defibrillator placed for an unknown arrhythmia. Now, she feels her heart beating in her chest, looks diaphoretic, is tachypnic, but her pulse is 58 and regular.

Resources used:

• G+
• Dr. Smith's EKG Blog
• Academic Life in Emergency Medicine

I looked on the monitor and she was beating away at about 60 bpm and it looked normal sinus rhythm. An EKG showed this:

Join me on G+.  I edited the grainy picture I took on my phone to what you see above in 2 minutes

The EKG was normal sinus rhythm and looked entirely normal except for this odd pattern in V2 (and somewhat in V1). Could it be a saddle-back? Is this Brugada syndrome?

I opened the Paucis Verbis card about Brugada by Michelle Lin on Academic Life in EM on my iPad and saw this:

I called the electrophysiologist, and I sent the EKG to his phone. I told him that I thought she had Brugada syndrome, and he told me it was something close, but not quite - because in V2 the J-point is not > 2mm. The patient would be fine because she already had the AICD placed. Some ativan, reassurance, and encouragment to call her insurance company to inquire about her outpatient mental health benefits fixed the problem. You'd be anxious too if you literally died earlier that week.

I went home after the shift and opened Dr. Smith's EKG Blog, searched Brugada and learned that the pattern could be unmasked by common occurances like fever, cocaine, propofol, and lidocaine. "Get this patient some Tylenol. We need to break his fever, STAT" I imagined myself saying next time I had a saddle-back with fever.

Brugada has a high incidence of sudden cardiac death. Although this was not a true Brugada, this patient who had an EKG that sure looked a lot like Brugada had suffered from sudden cardiac death. I'll leave the specific rules of diagnosing Brugada to the cardiologists - the saddleback is my can't miss diagnosis.

This is a guest series by Dr. Timothy Peck, who is launching his own blog at ModernEM.blogspot.com. Check it out!