No post today

Self-imposed, mandatory, spontaneous ski trip. 

I'm declaring today as one of many national "Wellness" days.

Be well.

Sorry for the no-post.

50 y/o female with history of alcohol abuse presents with diarrhea for the past several days. HR 120 BP 60/30. Exam notable for cachectic appearing female with dry mucus membranes and poor skin turgor. Patient is fatigued but has a non-focal neuro exam. Na 115 BUN 60 Cr 2.0. CBC normal. No baseline labs for comparison. What is your resuscitation fluid of choice?

While normal saline is generally the favored fluid for volume expansion, use of this fluid in patients with hypvolemic hyponatremia has lead to central pontine myelinolysis.  Consider use of 1/2 NS or alternating NS with 1/2 NS.  No matter what, closely monitor Na.


Source

Oh, M. et al.  "Case Report: Danger of Central Pontine Myelinolysis in Hypotonic Dehydration and Recommendation for Treatment"  American Journal of the Medical Sciences.  July 1989.

Paucis Verbis: Pneumonia risk stratification tools

Pneumonia is a common cause for ED visits. How do you decide on whether the patient can be managed as an outpatient or inpatient? To supplement your clinical judgment, many clinicians use the Pneumonia Severity Index (PSI) score.

Have you heard of CURB-65, supported by the British Thoracic Society? What about SMART-COP, which is meant to help you predict if your patient will need Intensive Respiratory or Vasopressor Support (IRVS)?

It's worth a quick review.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Prezi: A new age for presentations?

Presentations are traditionally given using Powerpoint. Keynote is prettier alternative to Powerpoint but is only Macintosh-compatible. Both have the same antiquated structure such that content is presented only linearly.

The hottest presentation tool now is Prezi, a web-based tool, which allows the viewer to zoom in and out of sections. The visuals are more of a conceptual map of the content, where the viewer or speaker can zoom around any desired topic. Because it's online, you can easily embed YouTube videos.

Take a look at this Prezi demo advocating it as a tool for teaching.

To navigate, you can click on the gray arrows at the bottom to advance forward or backward, as pre-programmed. Alternatively, you can drag the display using your mouse. Or you can zoom in/out using the + or - tools on the right.

Thoughts on using Prezi as a teaching tool on Prezi

What are your experiences with this?

You can also view a TED video where Chris Anderson uses Prezi as his slides.

At what glucose concentration can poorly controlled diabetics begin experiencing hypoglycemic symptoms?

Given that their bodies are used to higher than normal glucose concentrations, symptoms can start at 78 mg/dL which is considered a normal glucose concentration for most people.


Source

Mattu, A. et al.  Avoiding Common Errors in the Emergency Department.  2010.

Trick of the Trade: Embedding Google Docs document in blog

Google Docs is constantly improving and growing. One of the cool features is that you can embed any document within your blog. Whenever you edit the Google Docs document, it automatically updates in your blog.

How do I do this?

• Within your document in Google Docs, click on the upper right "Share" button and select "Publish to Web".
• In the pop-up screen, select "Start Publishing".
• Copy and paste the provided HTML code in your blog. 
• With a little HTML editing, you can make the optimize the margins bigger than the teeny preset dimensions. To change the margins to 440-pixel width and 500-pixel height, add the extra text (in bold) into your code as follows:

And ta-da! Embedded is my handout from a recent talk on mobile apps in Medicine.

The Microskills

It's a typical Saturday night in the department.  You're busy.  I mean really busy; the "too busy to make a run to the bathroom and empty your overly distended bladder" busy.  Your resident comes up to you with their next patient.  At first, you think of just hearing out the chief complaint, telling them what to order, and moving on to the next patient.  Fortunately, a voice in your head reminds you that there is a better way, a way to promote a morsel of learning despite the challenges stacked before you.  Enter the microskills.

The microskills model of teaching, also referred to as the "One Minute Preceptor," is a series of easily performed steps that allow you to maximize a teaching encounter when time is precious.  The steps are:

1. Get a commitment: I love using this step to shorten the presentations from my learners.  Too often, they get lost in the forest when presenting a case.  Simply stepping back and asking, "What do you think is causing their symptoms?" allows me to hone in on the important parts of their presentation.  I can then focus my questions to help me understand why they are concerned about possible conditions on the differential that they have created.  "I don't know" is not an acceptable answer.

2. Probe for supporting evidence: The follow up.  Once they take a stand, you're able to ask the why and what if questions.  The more direct questioning focuses them on the task at hand and allows you to understand the history a little better as well as determining the learners decision-making process.

3. Teach general rules: The time to teach a mini-lecture is not when time is limited.  Instead, focus on a key point of the case, whether a historical factor, workup issue, or interpersonal problem and teach short and succinct pearls.

4. Reinforce what was done right: Reward the learner for their efforts.  Point out the good catches on the history or exam, congratulate them on making the correct diagnosis or picking the most effective workup.

5. Correct mistakes: Feedback is always critical.  Point out errors in their decision-making and explain methods to correct them in the future.  Point them toward resources for future learning.

The microskills have been employed in clinical teaching for over 20 years now.  While effective use of the skills takes more than the allotted "one-minute" advertised by the other name, the skills are quite helpful at keeping the teaching encounter short and focused.  When it gets too busy to teach, reach into your armamentarium for this quick and easy teaching tool. You'll be glad that you did.

Reference:

Parrot S, Dobbie A, Chumley H, Tysinger JW. Evidence-based office teaching-the five-step microskills model of clinical teaching. Fam Med. 2006 Mar; 38(3): 164-7. PMID: 16518731 

EM Critical Care Publication

Hot off the press!

A new CME publication has emerged from the publishers of Emergency Medicine Practice and Pediatric Emergency Medicine Practice called EM Critical Care. This new publication is specifically geared towards manging critically ill patients in the ED. There will be 6 issues per year with each issue offering 3 AMA PRA Category 1 credits. Although it has not yet been released, it appears to have an impressive editorial board including Emanuel Rivers, Michael Gibbs, Benjamin Abella and Robert Arntfield. Oh, and did I not mention Scott Weingart from the EMCrit Blog? If it is anything similar to it's predecessors, it is guaranteed to be a hit!

Check it out here.

Don't forget from a previous post that Emergency Medicine Practice articles from 2007 and earlier are free online. That post can be found here.

Disclosure: I have no financial ties to the above mentioned publications. I'm just a satisfied subscriber.

What percentage of school-age children are asymptomatic carriers of pharyngeal Strep pyogenes?

10%

Therefore, in the absence of suggestive clinical findings, a positive culture or rapid strep test is likely to reflect incidental carriage.


Source

Wessels, M. "Streptococcal Pharyngitis"  N Engl J Med.  2011 Feb 17.

Patient returns from foreign travel with fever. How should this change your fever evaluation?

Common things being common, the usual sources of fever, recent travel or not, are still the usual sources. Proceed with a fever evaluation as normal but also consider sending off LFTs and a blood smear to screen for the following 6 common causes of fever after international travel.

1. Malaria - transmitted by mosquito, causes flu like illness, parasites on Giemsa-stained thick and thin smears, specific antibiotic treatment dependent on species of protozoa and sensitivity patterns
   
2. Dengue Fever - transmitted by mosquito, severe flu like illness - ie breakbone fever - +/- rash, leukopenia-thrombocytopenia-moderate elevations of LFTs, treatment is supportive
   
3. Typhoid Fever - transmitted by fecally contaminated food and water, flu like illness +/- rash, relative bradycardia (given fever), LFTs usually 2 - 3x normal, treat with fluoroquinolone
   
4. Rickettsial Infection - transmitted by arthropod vector, flu like illness +/- rash +/- eschar at inoculation site, leukopenia-thrombocytopenia-elevated LFTs, treat with doxycycline
   
5. Leptospirosis - transmitted by urine contaminated food and water, flu like illness, , most cases resolve spontaneously but can consider treatment with doxycycline, consider sending microagglutination test if confirmation of diagnosis needed
6. Hepatitis A
   

Source

Cavagnaro, C. et al., "Fever After International Travel" Clinical Pediatric Emergency Medicine. 2008.

House, H. and Ehlers, J. "Travel-Related Infections" Emergency Medicine Clinics of North America. 2008.

Article Review: Professionalism of physicians on Twitter

In a Research Letter in JAMA, Dr. Chretien et al describe the profile of physicians in the Twitter universe, specifically focusing on professionalism.

Inclusion criteria:

• Self identified physician
• At least 500 followers during May 1-31, 2010 (Whew, I only have 309 followers.)
• English tweets
• Posted a tweet within last 6 months

A total of 260 physicians were studied.

• 6.2% were from Emergency Medicine.
• 15% (most) were from Surgery and its subspecialties.
• 76% were from the United States.

Three physicians independently coded the 20 most recent tweets from each account (total n= 5,156) for unprofessional content. There were 144 (3%) unprofessional tweets from 27 users:

• 55 (1%) - possible conflict of interest, advocating for non-standard therapies
• 38 (0.7%) - potentially violation of patient privacy
• 33 (0.6%) - profanity
• 14 (0.3%) - sexually explicit material
• 4 (0.1%) - discriminatory statement
• 25 of 27 (92%) of users were identifiable 

The authors conclude that, although rare, there should be more physician accountability and guidelines in the age of social media. This is even more true, since I just discovered that all tweets are archived by the Library of Congress!

Take a look at your most recent tweets. How would they have performed if you were included in this study?

Reference
Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA: The journal of the American Medical Association. 2011. 305(6), 566-8. PMID: 21304081
.

Answer to "What is this patient's cardiac rhythm?"

According to the poll results, most MEMB readers thought that the cardiac rhythm was atrial flutter and this would be an excellent guess.  However, the rhythm strip which was obtained after administration of adenosine doesn't demonstrate the classic saw-tooth pattern of flutter waves but rather quite distinctive p waves (circled on EKG below).  These p waves can't be from the sinus node though because there's little variation in the heart rate over time - sticking consistently around 150 - and the PR interval is quite short (suggesting an ectopic focus close to the AV node).  Final diagnosis, as confirmed by EP study, was ectopic atrial tachycardia.  Patient was treated with EP ablation and did well.

Multiple lead rhythm strip obtained after adenosine administration.  Note distinctive p waves         (circled). Click pic to enlarge.

Can you get withdrawal symptoms from a placebo?

Source

http://twitter.com/professorfunk

What is the best way to learn?

1. Mnemonics
2. Test taking
3. Practicing weaknesses, ignoring strengths 

Two NY times articles deep dive into research which examine methods to optimize learning:

Test-Taking Cements Knowledge Better Than Studying, Researchers Say

Secrets of a  Mind-Gamer: How I trained my brain and became  a world-class memory athlete.

Paucis Verbis: Assessing patients with suicidality in the ED

Dr. Rob Orman of ERCast blog fame emailed me last week about creating a pocket card on Suicide Risk Stratification. In many community ED's, risk assessment is done by the emergency physician. I'm lucky where I work, because we have a 24/7 psychiatric ED, which consults on suicidal patients in the "medical ED".   

In the end, assessment is primarily based on physician judgment, because there's no great clinical decision tool, rules, or scores to assess risk. Rob has created his own mnemonic to help you ask the right questions in assessing a suicidal patient. This is a sneak peak into a larger article that Rob is planning to unleash on the world on suicide assessment. Based on his review of the literature and own clinical experience, the mnemonic is: TRAAPPED SILO SAFE.

TRAAPPED SILO

• "Risk factors" which increase a patient's risk for committing suicide in the near future. 

SAFE

• "Protective factors"which decrease a patient's risk for committing suicide in the near future.

Feel free to download this card and print on a 4'' x 6'' index card.
Thanks, Rob!!

* Updated 3/8/11: Added extra "A" to include "Access to Means" as a risk factor.

[MS Word] [PDF]

See other Paucis Verbis cards.

Hot off the press: MediBabble app

Ever since my post about the top medical apps, I have been inundated with people asking me to review their apps.

One has stood out.

Medibabble is a real-time medical translation app and is now available for FREE. It was created by two innovative UCSF medical school graduates, Dr. Alex Blau and Dr. Brad Cohn. This app contains an extensive preset list of history questions and physical exam commands. When you click on a sentence, the app will translate and speak the sentence in one of 5 languages (Spanish, Cantonese, Mandarin, Russian, and Haitian Creole).

Download MediBabble (takes you to iTunes link)

Take a few minutes to download all of the free languages onto your device. It only comes with Spanish pre-installed. There is a FAQ page at www.medibabble.com. The app is only available for the iOS platform currently.

Poll: What is this patient's cardiac rhythm?

27 y/o female patient presents with cough and runny nose for several days.  Vitals notable for HR of 150 but otherwise normal.  An EKG is obtained:

12 lead EKG.  Click pic to enlarge.

6 mg of adenosine given:

Multiple lead rhythm strip obtained while adenosine given.  Click pic to enlarge.

12 mg of adenosine given:

Multiple lead rhythm strip obtained while adenosine given.  Click pic to enlarge.

After each dose of adenosine patient reverted back to the rhythm, with associated rate, noted in the original EKG. What is the rhythm?


Answer to be posted Monday.

Trick of the Trade: Serial lactate measurements in sepsis?

Does your Emergency Department have computerized spectrophotometric catheters to measure continuous central venous oxygen saturation (ScvO2) in early goal directed therapy (EGDT) for severe sepsis? That's what was used in the original Rivers' EGDT study.

I've never even seen one before.

Many emergency physicians are getting around not having the specialized equipment issue by obtaining intermittent venous blood gas measurements off of a central venous line.

But what if you had a 30 y/o woman with early pyelonephritis/urosepsis who has severe sepsis by definition? She's got 10 peripheral lines (I'm exaggerating, of course), a normalized blood pressure with early IV fluids, and appears non-toxic. Her lactate, however, is 9! Do you really need a central line? My gut says no, but the EGDT protocol says yes -- for the purpose of CVP and ScvO2 measurements.

Trick of the Trade: 
Use a less-invasive approach where bedside ultrasound and serial venous lactate levels replace central venous lines and ScvO2 measurements, respectively.

Last year, JAMA published a landmark study showing that lactate clearance of ≥10% over the first 2 hours is "not a worse measurement" than ScvO2≥70%. This double-negative statistical speak came about because it was a non-inferiority study.

So how does this affect the original Rivers protocol? To review, here's the original protocol, which I posted about earlier:

(click to view larger image)

In the less invasive model:

• Fluid resuscitate through peripheral IV access instead of a central line. 
• Follow volume status either with a bedside ultrasound or urine output.
• Follow venous lactate levels at time 0 and 2 hours. If the lactate clearance is ≥10% over these 2 hours, you should follow the algorithm as if the ScvO2≥70%. That means no need for immediate transfusion or vasopressor agents.

How do you know when you have adequately volume-resuscitated a patient using bedside ultrasound? Measure the IVC diameter about 1-2 cm from the right atrium junction.

• If the IVC diameter ≤1.5 cm and has ≥50% collapse with inspiration, the patient has a very low CVP.
• If the IVC diameter is at least 1.5 cm and has minimal collapse with inspiration, the patient is euvolemic. Move to the next step -- assessing the MAP.

Pearl: 
This doesn't mean that all EGDT patient should have ONLY peripheral lines. Persistent hypotension, a non-clearing lactate level, and/or clinical toxicity warrant more invasive monitoring and management.

Scott Weingart has an in-depth, 21-minute podcast about the JAMA article and noninvasive approach to sepsis: Podcast link. Scott also briefly interviews Dr. Alan Jones (Carolinas Medical Center), the first author of the study, in the podcast.

Reference
Jones AE, et al; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA : the journal of the American Medical Association. 2010, 303(8), 739-46. PMID: 20179283
.

See you next week!

Sorry about the lack of posting this week.  I'll be heading to sunny Florida for a quick conference and a few days rest and relaxation.  I'll be back next Tuesday with a discussion of the microskills.  Talk to you then!

Hot off the press: Nominate someone for a CDEM award

CDEM was born here.

In its third official year, the Clerkship Directors in Emergency Medicine (CDEM) organization is still growing strong. It all started with six of us at an informal dinner in Boston about 5 years ago. And now the organization has grown so large that it is now for the first time offering annual awards to its members.

Know an award-worthy educator? Nominate him or her!

CDEM Clerkship Director of the Year Award
This award recognizes an Emergency Medicine Clerkship Director that has made significant contributions to either a 3rd or 4th year EM rotation. To be eligible for this award, the nominee must currently be a Clerkship Director of a mandatory, selective or elective rotation and have served in that role for a minimum of 5 years. This award is presented at the annual CDEM meeting.

CDEM Young Educator of the Year Award 
This award recognizes a medical student educator at the Clinical Instructor or Assistant Professor level and less than 10 year from residency completion who has made significant contributions to teaching and educating medical students.  This award is presented at the annual CDEM meeting.

CDEM Distinguished Educator Award 
This award recognizes a medical student educator at the Associate Professor or Professor level who has made significant contributions to and has demonstrated sustained excellence in teaching and educating medical students for 10 or more years. This award is not presented annually; rather, it is bestowed on special occasions.

CDEM Award for Innovation in Medical Education
This award recognizes a medical student educator at any faculty rank who has made a significant and innovative contribution to undergraduate medical education. This award is presented at the annual CDEM meeting.

Deadline: Mon, March 14, 2011.

Instructions on how to nominate someone for a CDEM Award can be found at the CDEM/SAEM Website.

Article Review: Generational differences in academic EM

Men are from Mars. 

Women are from Venus.

By learning about our differences, we can learn to appreciate and better communicate with those who are different from us.

The same falls true for working with residents and faculty from different "generations", as defined as traditionalists, baby boomers, generation Xers, and millennials.

This literature review and consensus document is quite extensive and even comes in 2 parts in Academic Emergency Medicine. There is a great summary table of the generational differences in personal, work, and educational characteristics, communication styles, and technology.

Think of faculty who fit in these age groups. Do they fit their generational stereotype?

Traditionalists (born 1925-1945)

• Personal characteristics: Loyal, reluctant to change, dedicated, value honor and duty, patriotic
• Work characteristics: Value hierarchy, loyal "company man",  job security
• Education characteristics: Process oriented
• Communication style: Formal
• Technology: Tend not to understand

Baby Boomers (born 1945-1964) 

• Personal characteristics: Optimistic, desire for personal gratification, highly competitive 
• Work characteristics: Workaholic, competitive, consensus builder, mentor 
• Education characteristics: Learner depends on educator, lecture format, process-oriented 
• Communication style: Diplomatic 
• Technology: Not particularly techno-saavy 

Generation Xers (born 1964-1980) 

• Personal characteristics: Independent, self-directed, skeptical, resilient, more accepting of diversity, self-reliant 
• Work characteristics: Value work-life balance, comfortable with change, question authority 
• Education characteristics: Independent learners, problem-solvers, desire to learn on the job, outcome-oriented 
• Communication style: Blunt 
• Technology: Interested and facile

Millennials (born 1980-1999)

• Personal characteristics: Optimistic, need for praise, collaborative, global outlook 
• Work characteristics: Team-oriented, follows rules and likes having structured time, career changes 
• Education characteristics: Team-based learning environment, turn to Internet for answers, outcome-oriented 
• Communication style: Polite 
• Technology: Very saavy, technology is a necessity 

The authors give multiple examples where generational differences come to light but none more so than in mentorship within the academic department.

• Traditionalists view mentorship as a more formal process, where feedback is necessary only to provide criticism or suggestions for improvement.
• Baby boomers also view mentorship as a "top down" process. They are ok with infrequent interactions.
• Generation Xers and Millennials prefer mentorship as a more "peer to peer" process with more frequent interactions. They value the personal relationships and the opportunity to collaborate in creative solutions. Because of their stereotypical distrust of authority, however, they may inadvertently sabotage their relationship with their mentors. Distrust sometimes is misinterpreted as a general lack of respect. 

To overcome these differences, mentor-mentee pairings should take into consideration gender and shared views about goals, work/life balance, and experiences. Early discussions in a mentorship relationship should discuss generational differences and how each envisions the ideal mentor-mentee relationship to be. The pair should agree upon and adopt a collaborative, shared communication approach with frequent feedback.

So much more in this article... Take a read.

Reference Mohr NM, Moreno-Walton L, Mills AM, et al. Generational Influences in Academic Emergency Medicine: Teaching and Learning, Mentoring, and Technology (Part I). Acad Emerg Med. 2011, 18:190-9, 10.1111/j.1553-2712.2010.00985.x
.

How long should a patient who overdosed on opiates and required narcan for respiratory resuscitation be observed in the ED prior to discharge?

About 5 hours.

Half life of narcan is 1 hour. At five half-lives, or 5 hours, the initial dose of narcan is 97% eliminated and if the patient has not required another dose of narcan for recurrent respiratory depression by this point, it is probably safe to discharge the patient home.

Click on image to enlarge

Source

Naloxone: Drug information. Lexi-Comp

Image source: http://www.nes.scot.nhs.uk/prescribing/topics/TDM/fig2.gif

What are the main advantages of Fosphenytoin (Cerebyx) over Phenytoin (Dilantin)?

Fosphenytoin is more water soluble and does not require dilution with propylene glycol and alcohol.  Consequently, this drug lacks phenytoin's adverse effects such as hypotension, cardiac arrhythmias, and infusion site reactions; and can be given at a much higher IV infusion rate 150 mg/min (relative to 50 mg/min) or, if necessary, even given IM.   The main disadvantage used to be cost but Fosphenytoin is now available generically. 


Source

Hung, O. and Shih, R.  "Antiepileptic Drugs: The Old and the New"  Emerg Med Clin N Am.  2011.

Need an ENT foreign body hook but don't have one in the ED? Try this ...

Improvised foreign body hook.  Cost: $0.01

Made from a paper clip; you can shape the tip for optimal foreign body removing power!  Perfect when you're in a bind and don't have one of these:

Bausch + Lomb Ear Hook.  Cost: $35.00

Source

http://www.bauschinstruments.com/product-details.aspx?pid=9395

Paucis Verbis: First-Line Treatment for Hypertension

A 50 year-old woman, who presented to the ENT clinic for followup check of a facial fracture, has a blood pressure of 210/100. She is asymptomatic and in no pain. She gets referred immediately to the ED for care.

Now you see her in your ED. What next? 

There is a lot of controversy whether you should treat or not treat asymptomatic hypertension in the ED. The ACEP Clinical Policy says that there is no need to immediately reduce an asymptomatic patient's blood pressure. With "close followup", they can be referred to their primary care physician. 

With so many patients being uninsured or unable to access their primary care physician on short notice, many emergency physicians like myself are slowly moving towards starting antihypertensive medications for them.

If you do decide to start an antihypertensive, which medication do you choose? This Paucis Verbis card is based on a 2009 Cochrane Review, and summarized in American Family Physician in 2010. The blue numbers denote a Risk Ratio (RR) which cross 1, meaning that there is no benefit. The red numbers denote a RR < 1, meaning that there IS a benefit.

Bottom line: 
A low-dose thiazide, such as hydrochlorothiazide 12.5-25 mg po daily, is a safe and effective choice.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

References
Quynh B. Cochrane for clinicians. First-line treatment for hypertension. Amer Fam Phys. 2010, 81(11), 1333-5.
Mensah G, Bakris G. Treatment and Control of High Blood Pressure in Adults. Cardiology Clinics. 2010, 28(4), 609-22. 
. .

Whither bedside teaching?

Observe, record, tabulate, communicate.  Use your five senses.  Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone you can become expert.  Medicine is learned at the bedside and not in the classroom.  Let not your conceptions of disease come from words heard in the lecture room or read from the book.  See, and then reason and compare and control.  But see first.

-Sir William Osler

I recently received my quarterly faculty evaluation.  I usually take a cursory look into the scores and file the report away for future reference.  On occasion, the residents take the time to write some useful comments that help me to become a better teacher.  I was a little surprised by such a comment with this evaluation:

"Please do not ask the resident medical questions in front of patients, wait until we have exited the room."

In my practice, I find it exceedingly difficult to go to the bedside with my learners.  I often fall victim to the nursing station presentation as I hurry off to see other patients.  Despite this, I make the occasional effort to get to the bedside with my residents and students.  As Osler points out, the best learning is that which is done at the beside with a patient.  While less frequent than I desire, these encounters are fulfilling as a teacher and really allow me to see my learners in action.

Perhaps that is why I find the above comment troubling.  Have we abandoned the bedside for so long that our learners are so uncomfortable in front of patients with a teacher?  Are they so afraid of appearing to be wrong when asked more advanced questions?  I can respect their fear.  I've been there.  I have also learned far more from being wrong and making mistakes.  It's simply part of being a learner.   

Reflecting upon the comment, I decided to pull out one of my favorite articles on bedside teaching and review some tips for making it work.

Before going to the bedside:

Prepare: Formulate goals, know learning needs of your students and residents

Orient learners: Learners should know what is expected before going in.  I guess I have failed to explain to them that it is okay to be wrong.  Uncomfortable, yes, but still okay.

Orient Patients: Let the patient know everyone and their role; they should already know the learner.  Explain that you'll be asking some medical questions and make sure to thank them for their role in teaching the learner

At the Bedside:

Establish the environment: Try to make the atmosphere comfortable.  I try to keep the discussion less formal.  I'll ask some clarifying questions of the patient and then focus on the learners.  The key is to challenge them intellectually without humiliating them.  

Respect learners and patients: Be human.  You must remain sensitive to the patient and how illness affects them.  I do find that patients enjoy learning at the same time as the learners.  Often, the medical discussion forces me to really focus on communicating the same information to the patient in a manner that they can understand.

Engage everyone: Often not a problem where I practice; usually it is just one learner, but if you teach in a setting with a lot of learners, make sure you have questions for all, from the beginning medical student to the PGY-IV resident.

Involve the patient: Make sure to allow the patient to correct unclear parts of the history.  Make sure that they're able to ask questions as well.

Match teacher and learner goals: This topic fits into the "before" category as well.  I try to start my shift by asking my learners what their goal for the day will be.  This allows me to cater the learning to their needs and wants.  With residents, I'm also able to cater to their deficiencies since I work with them often.

After leaving the bedside:

Debrief:  This has 2 purposes: clarify the encounter and plan and to provide feedback.  The learner gets some time for questions, we finalize our workup plan, and then I can provide brief feedback on how to improve.

While bedside teaching is underutilized, with practice it is one of the best clinical teaching tools.  We all have something to offer to our learners, sometimes skills that can only be learned through observation, practice, and reinforcement at the bedside.  Unless we go there and face our (and our learners) discomfort, we cannot begin to realize our full potential.

Reference:

Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003 Apr;78(4):384-90. PMID: 12691971

What is the physician fee for a level 5 ED visit compared to a CABG?

$316: level 5 ED visit

$3714: CABG

These and other health care costs can be found at Healthcare Blue Book a website which publishes the price insurance companies pay for various health care expenses. While the website is not all inclusive, it is still an interesting site to peruse as much of this pricing information is not readily available.  While I can't vouch for the accuracy of all the information, the ED rates cited seem to be on par with medicare reimbursement rates.


Source

http://healthcarebluebook.com/page_Default.aspx

EMRAP Education Podcast: Educational Resources in EM

Dr. Rob Rogers has posted his 21st podcast on EMRAP Educator's Edition. The topic is "Educational Resources in Emergency Medicine".

Listen to why you need to know about these resources:

Upcoming Conferences:

• Council of Residency Directors (CORD) in EM (San Diego, CA)
• EM in the Developing World (Cape Town, South Africa)

Authors:

• Garr Reynolds (Amazon links to his books: Presentation Zen, Presentation Zen Design, The Naked Presenter)

Websites:

• TED Talks
• Academic Life in Emergency Medicine ... Hey wait! Cool. That's me! Thanks for the shout out, Rob.
• ERCast - Podcast interviews hosted by Dr. Rob Orman (free)
• EMCrit - Podcast summaries by Dr. Scott Weingart on critical care topics (free)
• EMRAP Critical Care Edition - Podcast with Dr. Michael Winters, Dr. Peter DeBlieux, and Dr. Rob Rodriguez ($60 annual subscription)
• EMCast - Monthly podcast interviews with Dr. Amal Mattu through Emedhome.com ($99 annual subscription)
• CDEM Curriculum - Resource put together by CDEM for medical students which includes essentially an online textbook in EM (free). Rob even put in a plug for my Digital Instruction in Emergency Medicine (DIEM) online simulation cases. I'm not actually done with all the cases, as Rob suggests! Only the first case on Chest Pain is done thus far... Ack! I better get crackin' now.

Spend a high-yield 25 minutes listening to Rob's take on need-to-know educational resources in EM.

Trick of the Trade: Conveying risk for postexposure prophylaxis

A health care worker hurried in to the ED after being poked with a needle.

'It was an old 18G needle with dried blood', she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, 'What does very low risk mean?'

Is there another way to covery risk for patients?

Trick of the Trade:
Convey probabilities with everyday risks.

This article uses a risk stratifying tool to convey probabilities that compare to everyday risks such as flying, cancer diagnosis, having an MI, etc. Below is the calculation tool from the paper.

Using this tool, the risk of contacting HIV for this patient would be:

5/ (1000 x 100 x 100) = 1/ 2,000,000

According to the everyday risk table in the article, this is similar to the risk of dying in the next 12 months from lightning. You left her to decide on PEP.

My take:

As the author pointed out, the risks cited are probabilities instead of exact measurements. This is an important caveat.

I find this helpful to provide context, especially for those who have difficulty deciding on PEP.

Reference
Vertesi L. Risk Assessment Stratification Protocol (RASP) to help patients decide on the use of postexposure prophylaxis for HIV exposure. CJEM : Canadian journal of emergency medical care. 2003, 5(1), 46-8. PMID: 17659153

Read the free article from CJEM. 

Safe Patients, Smart Hospitals

Peter Pronovost, MD, PhD is a name synonymous with patient safety.  He and his team have made patient safety a respectable area of expertise within the house of medicine.  He recently published a book, Safe Patients Smart Hospitals, which explains his quest to improve patient safety, first at Johns Hopkins, and now across the country.  While well written, I wouldn't recommend it to the random reader unless you have an interest in patient safety.

As someone who has a strong interest in making my patients safer, I found many helpful pearls within the pages.  As many of you know the recent media has a myopic focus on checklists as a major way to reduce error.  This is partially due to a misunderstanding of the work that Dr. Pronovost's team has performed.  While checklists do work, and that is clear from the NEJM article listed above, 2 very important facets of their technique have been somewhat ignored: changing culture and rigorous data gathering.

As Dr. Pronovost explains, patient safety depends on 3 things: Translating Research Into Practice (TRIP), a Comprehensive Unit-based Safety Program (CUSP), and rigorous data collection.

TRIP and CUSP have since morphed together into an inseparable approach to teaching about safety.  The two are difficult to discuss as separate entities and as I learn more, I hope to share more details with you.

TRIP is the approach to a problem from a research standpoint; it is the background research.  When they first began their central line project, the team went through all of the guidelines, recommendations, and original research and boiled it down into 5 practical points that needed to occur to reduce central line infections.  This became the checklist.

CUSP is all about culture, and changing culture.  Personally, this is where the rubber meets the road.  Without addressing culture, challenging the status quo, and making people accountable to their actions, a checklist is just a piece of paper sitting in a stack somewhere.  The CUSP program works with the individuals, identifies where failures occur, and changes the status quo. It encourages people to speak up, and gives them the authority to be able to.  It was fascinating to read about the challenges their team faced when moving from one unit to another and how CUSP made all of the difference.

The final important factor in patient safety is rigorous data collection.  Remember "Measure Something?"  This is often the limiting factor in safety research.  The data must be as good if not better than any other research trial or else the conclusion cannot be supported, and therefore, the intervention will be questioned.  The point is made over and over: Physicians are scientists at heart.  It is so true.

So what does this mean to an emergency physician?  If you take the 30,000 foot view, this is a very simple and easily reproducible approach to create change:

-Identify a problem
-Look for evidence of how to fix the problem
-Simplify the solutions as much as possible, you really want a short list
-Start to institute it in your department.

Just like in education, make sure to give feedback to your team on how they're doing, as well as soliciting their input.  If you do this and combine it with strict data collection, you will likely see marked improvements in the departments' morale all while making the care you provide much, much safer.

Didactic videos for rotating residents the ED

Many academic Emergency Departments are staffed by non-EM residents. Dr. Amer Aldeen and his super-star team from Northwestern created NURRC Modules (Northwestern University Rotating Resident Curriculum). These modules allow the off-service residents, who all have different schedules, to learn key EM-based topics at their own leisure and convenience.

The positive effect of the curriculum on the off-service residents' medical knowledge was recently published in Academic Emergency Medicine: Read my review.

NURRC Video Modules:

1. ENT and Ophthalmology Emergencies
2. Environmental Emergencies
3. Obstetrics and Gynecology Emergencies
4. Orthopedic Emergencies
5. Toxicology
6. Trauma and Wound Care

Thanks to the team for agreeing to make these videos free for everyone to use.

I hope I wasn't too pushy or forward in asking for the videos... and then asking if I could post then all on YouTube! Such a great resource shouldn't live behind closed doors. I'll post the other 3 videos once I receive them from Amer.