P-video: Remembering NEXUS criteria

Accuracy
Valid for practice
True to literature
Overall quality

Please peer-review this blog post by clicking on the stars above.

View all P-Videos

PV card on Cervical Spine Rules:

Canadian C-spine Rules (CCR)

References

1. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998 Oct;32(4):461-9. PubMed PMID: 9774931.
2. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000 Jul 13;343(2):94-9. Erratum in: N Engl J Med 2001 Feb 8;344(6):464. PubMed PMID: 10891516.
3. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510-8. PubMed PMID: 14695411.

If you are interested, you can view the results of the Peer Review Demographics data.

Patwari Academy videos: Presenting patients in the ED

Doing well on your Emergency Medicine rotation, whether you are a medical student or resident, will depend in large part on your ability to deliver a coherently concise presentation to the senior resident or attending physician. It's about telling a story that fits into the construct of how the expert physician thinks.

If you ask 20 attendings physicians what the perfect presentation is like, you'll get 40 different answers. I know, frustrating. Rahul's video describes a reasonable approach and thought process.

We've also covered this hot topic on this blog:

• The 3-minute presentation
• Improve your public speaking skills

Related links:
1. Teaching Residents from Other Services: EM-RAP Educators Edition
Rob Rogers (@EM_Educator) and Michelle Lin (@M_Lin)

2. Medical Student Presentation
Rob Rogers (@EM_Educator), George Willis, and Adam Friedlander 

3. How to give a good ED Presentation

Steve Carroll (@embasic)

4. How to think like an emergency medicine physician
Reuben Strayer (@emupdates)

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.

Trick of the Trade: Reducing the metacarpal fracture

Metacarpal neck fracture reduction 

General principles of fracture reduction involve axially distracting or pulling on a fracture fragment and pushing the piece back into anatomical alignment. This can be seen in the video above (automatically starts at 2:25 for the actual procedure). What if this approach doesn't work? The fracture fragment remains immobile despite your best efforts.

Image from AO Foundation

Trick of the Trade:
Jahss reduction technique

This technique, also known as the 90-90 approach, involves flexing the patient's MCP and PIP 90 degrees. Dorsal force is applied to metacarpal head by through dorsal pressure on the proximal phalanx. The 90-90 positioning also stretches the collateral ligaments of the MCP joint, which further optimizes the reduction technique.

Although this cool animation below was intended for patient education, it nicely illustrates how the Jahss technique works.

See the Paucis Verbis card on Metacarpal Fractures.

Patwari Academy videos: Primary and secondary assessment

Deer in headlights

That was me as a medical student, when I first encountered an undifferentiated patient in moderate distress. The trick is to have a standardized primary and secondary survey approach. Sometimes it takes just a little kick-start to get you thinking and doing.

More great videos by Dr. Rahul Patwari:

P-video: How to remember the GCS scoring

In this inaugural P-video, Dr. Jeremy Faust gives us a quick way to remember how keep the maximum subscores of the Glasgow Coma Scale straight. There's verbal, motor, and eyes. Which has a max score of 4, 5, and 6?

View all P-videos

New video series: P-Videos by Dr. Jeremy Faust

Welcome to the blog Dr. Jeremy Faust, who is currently an emergency medicine resident from Mount Sinai Hospital and Elmhurst Hospital Center. He's a frequent contributor to ACEP News, a proud proponent of Free Open Access Medical Education (#FOAMed), and a classical musician and producer. We extremely lucky to have Jeremy join our ALiEM blog team.

What are P-Videos?

Paucis Videos (paucis means "few" or "brief" in Latin) are short video-based educational pearls for the practicing physician with a focus on Emergency Medicine and Critical Care. The videos are meant to be extremely short so that they can be easily referred to at any time. These videos build upon concept of brevity with the Paucis Verbis ("in a few words" in Latin) cards, which provide condensed nuggets of clinical information on a 4x6 inch index card.

The P-videos take it up a notch by covering such items as:

• Medical mnemonics
• Instructional videos
• "Tricks of the trade"
• Rapid-fire journal reviews

Enjoy and please suggest topics and provide us with your feedback!

Trick of the Trade: Ossification centers of the elbow

Fracture or a normal ossification center?

This is a common question heard when viewing an xray of a pediatric elbow. How do you remember the timing of normal ossification centers? FYI, the xray images above are normal and have no fractures.


Trick of the Trade:
The mnemonic CRITOE 1-3-5-7-9-11

• Age 1 year:    Capitellum
• Age 3 years:   Radial head
• Age 5 years:   Internal (medial) epicondyle
• Age 7 years:   Trochlea
• Age 9 years:   Olecranon
• Age 11 years: Extrenal (lateral) epicondyle

This great video is from a relatively new YouTube channel that I stumbled upon called "Radiology Channel", which is a Radiopaedia.org project featuring short polished presentations by Dr Andrew Dixon, Dr Frank Gaillard and Dr Jeremy Jones.

Patwari Academy videos: ACLS and post-resuscitation care

This is the last installment of Dr. Rahul Patwari's digital whiteboard video talks on ACLS, specifically focusing on post-resuscitation care and therapeutic hypothermia.

• Parts 1-3 (ACLS and airway)
• Parts 4-6 (ACLS: cardiac arrest)
• Parts 7-10 (ACLS: bradycardias and tachycardias)

To debrief or not?

Learners have limited time. Residents have work hours restrictions, practicing physicians have work / life demands, and the list goes on. Time is valuable. Therefore, educational interventions must be hard-hitting, effective, and worthwhile.

We discussed previously "What is debriefing?" Debriefing is a facilitated discussion and reflection about objectives previously chosen by the educator. Dr. Ernest Wang (NorthShore Center for Simulation and Innovation) states that it's about getting learners to that “aha!” moment.

NCSI CSTAR Facilitative Debriefing Video from Ernest Wang on Vimeo.

According to Fanning and Gaba [1], deciding when to debrief is twofold:

1. Do participants lack a sense of closure? 
2. Can we derive useful insights through a discussion of the experience? 

Therefore, we debrief to give participants a conclusion to their learning experience, a manner by which to derive conclusions. We also debrief to provide insights as a group that may not be possible to derive as individuals.

Dr. Roger Greenaway is a UK PhD who specializes in training organizations on the benefits of active and experiential learning.  His website has published a list of 10 reasons on why to review (aka debrief).  These are some of the important points:

• Getting unstuck: Debriefing helps the learner to progress in the cycle of learning and development. 
• Opening new perspectives: Learners can understand complexities in medical management and realize that there is more than one right answer. 
• Developing observational awareness: We all want to become thoughtful and observant physicians able to gather subtle patient clues and condense medical information quickly. Debriefing helps to point out missed clues.

Think of debriefing as a way of accelerating knowledge acquisition and takes learners to the next level. So it is definitely hard hitting!

This is the second of several blog posts on debriefing. Future write ups will discuss the evidence behind debriefing, debriefing techniques, and where to get formal training in debriefing.

References

1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007. Summer;2(2):115-25. PMID 19088616.
2. Thiagarajan S: Using games for debriefing. Simul Gaming 1992;23: 161–173.

Trick of the Trade: Speed up ECG paper rate to differentiate tachycardias

Undifferentiated tachycardias, especially when the rate is extremely fast, make it difficult to see anything other than the QRS complexes! Is there a P or flutter wave?

Trick of the Trade:
Double the ECG paper speed to 50 mm/sec

Standard ECG machines run at 25 mm/sec. If you double the paper output speed, subtle ECG findings hidden in the tracings become more evident. Imagine the ECG tracing as a string and that you are pulling on both ends. Everything, including the QRS complex and intervals, gets wider.

What are your experiences with this?

Atrial flutter at 150 bpm:

• Standard rate 25 mm/sec 

• Faster rate 50 mm/sec (red arrows are flutter waves)

Thanks to Dr. Amal Mattu for sharing his ECGs with me from his University of Maryland ECG archives. If you haven't heard of this amazing ECG video series, you should definitely check it out.

Below is the video teaching this point within the topic of narrow-complex regular tachycardias. This trick is seen at the 15:00 minute mark.

For another example, check out Dr. John Larkin's blog ECG of the Week post on a pediatric SVT rhythm at 300 bpm with no P waves seen at 50 mm/sec.


Reference
Accardi AJ, Miller R, Holmes JF. Enhanced diagnosis of narrow complex tachycardias with increased electrocardiograph speed. J Emerg Med. 2002 Feb;22(2):123-6. Pubmed .

Gaspar JL, Body R. Best evidence topic report. Differential diagnosis of narrow complex tachycardias by increasing electrocardiograph speed. Emerg Med J. 2005 Oct;22(10):730-2. Pubmed Free PDF

Patwari Academy videos: ACLS (parts 7-10)

What is the definition of bradycardia and tachycardia in the 2010 ACLS guidelines, for the purposes of resuscitation algorithms?

• Bradycardia: heart rate < 50 bpm
• Tachycardia: heart rate > 150 bpm

Below are the next 3 video installments of Dr. Rahul Patwari's digital whiteboard talks on ACLS. These videos cover both bradycardias and tachycardias.

Trick of the Trade: Ultrasound-guided supraclavicular central line

Subclavian central lines are commonly touted as the central line site least prone to infection and thrombosis. The problem is that they are traditionally performed without ultrasound guidance. They are done blindly because of the transducer's difficulty in getting a good view with the clavicle in the way.

Trick of the Trade:
Ultrasound-guided supraclavicular approach to subclavian line

What are the surface anatomy landmarks for the supraclavicular line?

• Identify the border of the clavicle and lateral margin of the clavicular belly of the sternocleidomastoid muscle. 
• Insert the needle there and aim for the contralateral nipple, aiming anteriorly 10-20 degrees to avoid puncturing the subclavian artery and lung.
• You are trying to cannulate the near the juncture of the IJ and subclavian veins. 

If you just want to see the crux of the procedure, which uses the linear transducer to guide the long-axis needle insertion approach, start at 8:18.

Disclaimer: I do not have any commercial affiliations with Sonosite.

Reference
Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: the forgotten central line. West J Emerg Med. 2009 May;10(2):110-4. Free access to PDF

Patwari Academy videos: ACLS (parts 4-6)

Below are the next 3 video installments of Dr. Rahul Patwari's digital whiteboard talks on ACLS. These videos cover:

• Cardiac arrest (Vfib and Vtach)
• Cardiac arrest (More of Vfib and Vtach)
• Cardiac arrest (Asystole and PEA)

I love that each video is less than 15 minutes long. Also, even if you aren't a medical student, these are great refreshers. For instance, don't forget that atropine is no longer on the 2010 ACLS algorithm for asystole.

Trick of the Trade: Sterile cover for linear ultrasound probe

You decide to use ultrasonography to help you establish peripheral IV access for and obtain blood cultures from your patient. How can you ensure that you get a sterile sampling to avoid blood culture contamination? Do you need to open a full central-line ultrasound probe cover?

Trick of the Trade:
Use a sterile glove

Thanks to Dr. Haney Mallemat (Univ of Maryland, @CriticalCareNow) for the video and tip.

Patwari Academy videos: ACLS and the Airway

ACLS Lite: Introduction

This above video is a 2-minute introductory video on the ACLS video series. Below are the first 2 (Airway) of 11 video discussions on the various elements of the ACLS.

Seth Godin's TED talk on "Stop Stealing Dreams"

Seth Godin, a marketing guru, discusses his opinion about “what school is for” in this above video. Although this talk or Seth Godin are not directly related to medical education, this is still related to education and can still be applied to today’s medical education curriculum in many aspects.

Mr. Godin goes on to explain that school was modeled in the industrial age and has changed little ever since. The video covers such concepts as:

• Standardized exams in the industrial age were used as a tool to sort students. The person who created the standardized exams later on came to believe that the standardized exams were too crude, but due to his new conclusions he was excluded from his field. 
• Teachers in the industrial age believed that school was about teaching obedience and respect. 
• The industrial revolution created products en mass, but also needed people who were educated on consuming these products in order to survive. Therefore, schools were also created to educate people (or make replicas of people) about these products.

Mr. Godin states that people are more inclined to do more if it’s art, but do less if it’s work. He also says that now we are more intrigued in interesting stuff, but schools are dissuading us from being creative. With the help of technology: 

• We are finding out new ways of learning so that we don't depend so much on the person standing in front of a classroom giving a lecture. 
• We can read about what interests us
• We can view lectures from experts
• We can learn anything with the help of the internet. 

He then goes on to enumerate 8 things to answer what school is for, or better yet, how he thinks school SHOULD function:

1. Homework during the day, lectures at night.
This sounds like the concept of “flipping the classroom” (similar to Khan's Academy) where students watch lectures at night and come to school to work out problems during the day with their teachers.  

2. Open book, open note all the time.
“There is zero value memorizing anything ever again. Anything that is worth memorizing is worth looking up.” I’m not sure if I agree with this 100%, but it sounds similar to another quote by Albert Einstein about memorizing “Never memorize something you can look up.”
3. Access any course, anywhere, anytime in the world when you want to take it.
This is an example of asynchronous learning such as Coursera.
4. Precise focused education instead of mass batched stuff.
I think this is one of the most important goals in medical education. Our education needs to be specific as to what is relevant when it comes to patient care. Information has exploded in the past few decades, but medical school still modeled as it was created 100 years ago when there was not as much information around.

• No more multiple choice exams: According to Seth Godin these were made because they are easier to score, but now computers are smarter.
• Measure experience, instead of test scores: “Experience is what we really care about”
• Cooperation instead of isolation: Seth Godin states when we finish school we go out in the world to collaborate with others so we should value collaboration and not so much isolation.

5. Teachers will transform into coach(es).

6. Lifelong learning with work happening earlier in life.

7. Death of the "famous college". 
Seth Godin puts emphasis on defining the "good colleges", but he also states we don't know what a good college is.

     
8. Teach students to create something interesting and ask if you need help.
Things we should not be telling students according to Mr. Godin:

• Do not to deviate from the curriculum
• Better, better, better, better comply
• Do not ask questions I do not know the answers to
• Do not figure it out
• Do not look it up
• Be like your peers

The concept is that the more the student deviates from the "standard" the more difficult it is for the teacher to process the student.

Seth Godin ends the video by busting two myths:

1. Great performance in school lead to happiness and success. If that’s not true, we should stop telling ourselves it is.
2. Great parents have kids who produce great performance in school. If that’s not true we should stop telling ourselves it is.

Mr. Godin states we don't teach students to connect the dots, but rather to collect dots and memorize facts. He also declares that passion and insight are reality, while grades are an illusion. He returns to the question "what is school for?" and if we don't know, then we should have a conversation about it.

I think this is an important talk by Seth Godin and we must find which points we can apply to improve our medical education. Which points from Mr. Godin's talk do you think can be applied to improve medical education? Do you already know examples in medical education in which his points are already implemented? What is school for?

Links and references:
Seth Godin’s homepage
Seth Godin’s page on TED
Seth Godin’s blog
Seth Godin's wikipage

Image 2 source: http://northernfactoryworker.blogspot.com/2010_12_01_archive.html

Eavesdrop into LIVE International EM Faculty Development Conference

Today is the second day of the International EM Faculty Development and Teaching Course hosted at the University of Maryland by Dr. Rob Rogers and Dr. Amal Mattu. Although unable to attend, I have been able to be a virtual participant in real-time for many parts of the large-group didactic sessions.

Have you heard of Livestream?

Although I am always a little wary of these real-time video captures of lectures because of all the problems that might arise and the logistics with joining in, I decided to try the provided link:

http://new.livestream.com/iTeachEM/theteachingcourse

It was surprisingly hassle-free. With one click, I started immediately to view the talks and read the comment stream without logging in. The video and audio are surprisingly clear and smooth. Give it a try. I'm a convert. Would love to see more conferences utilize this technology!

I caught a talk by Amal on the nuts and bolts of bilding an academic niche. I wish I had heard these talks when I first started out as a faculty member!

Planned Livestream times (Eastern Standard Time)

Today, Nov 13 - this afternoon

Wed, Nov 14 -

• 1-2 pm
• 2:20-3:45 pm
• 3:45-4:45 pm

Thu, Nov 15 -

• 10:20-11 am
• 1-2 pm
• 2:30-3 pm

Fri, Nov 16 -

• 8-10 am
• 10:20 am-12 pm

New video series for med students: The "Patwari Academy"

Similar to Salman Khan of the Khan Academy, which is famous for "flipping the classroom", Dr. Rahul Patwari is a one-man innovating machine at Rush University's Department of Emergency Medicine. He has been creating digital whiteboard "chalktalks" on common EM conditions for the past year, which target the senior medical student. These 2-15 minute videos are way too amazing not share with the EM community of learners. I bet these would be really great supplemental learning material for EM medical students everywhere.

The above video (Status Epilepticus) is the first of a series of at least 40 videos thus far.

Thanks to Rahul for graciously allowing me to embed and share these videos. I'll be posting about one of his videos per week.

I joined Twitter. Now what? (Tutorial video #2 - Desktop)

In Part 2 of this Twitter tutorial (Part 1 video), I focus on how to navigate Twitter using the Twitter native website on my desktop/laptop. I personally, however, use Hootsuite (free) so that I can see more items at a single glance.

NOTE: You may have to increase the quality of the video because of the small print. You can do this at the bottom bar of video (uploaded in 720p).

Pearl:

• Start by following just a few people and build up to a bigger list. If often feels like you are drinking from a firehose if you start too quickly. Start with this list by @FOAMstarter.