Paucis Verbis: Delayed sequence intubation

A 40 y/o man presents with significant agitation and severe respiratory distress from a COPD exacerbation. His oxygen saturation is 75% on room air, and he has diffuse, tight wheezes on exam.

You prepare to intubate the patient using a rapid sequence induction protocol: etomidate, succinylcholine, 8-0 endotracheal tube.

Or do you? 

This Paucis Verbis card discusses the delayed sequence intubation (DSI) protocol made famous by Dr. Scott Weingart (EMCrit blog). Thanks to Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob Bryant (Intermountain Medical Center in Utah) for designing this helpful card. Rob has even implemented a DSI protocol in his ED. 

The card breaks down the reasoning and steps behind DSI. Anecdotally, ketamine has often calmed patients down enough during the preoxygenation phase to enhance oxygenation/ventilation so much so that intubation is not required. 

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

[MS Word] [PDF]

See other Paucis Verbis cards.

References

Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. PubMed PMID: 22050948. Link to free PDF

The 3-minute EM student presentation

One of the most helpful articles I’ve encountered on teaching oral clinical presentations in the ED is a paper from Academic EM in 2008. 

When we talk to one another, or talk to consultants about cases it is crucial for us to be concise and include all salient points of the history and physical. Because what you say (or don't say) could compromise patient care, it is important to instruct the medical student how to do this. As the paper explains, students learn to perform oral clinical presentations in other services, which are quite different from presentations in the ED.

The article describes one acronym SNAPPS, developed for the outpatient setting:

• S: Brief summary of the patient’s history and physical
• N: Narrowing the differential to two or three etiologies
• A: Analyzing the information to determine the most likely cause of the chief complaint
• P: Probing the attending for knowledge by asking questions
• P: Planning the patient's management
• S: Selecting an issue related to the case for self-directed learning.

Important characteristics that make EM unique:

1. Assume that every patient has a life or limb-threatening condition 
2. Juggle multiple patients simultaneously 
3. Prioritize patients according to level of concern 
4. Address patient loyalty, follow up issues, and consequences of incomplete medical records 

The HPI
Typically, novice students typically think to present the HPI of their case as below (in chronological order):

A better way to present should be in the order of importance (especially because the person listening likely will have waning attention span...):

After the chief complaint is stated, to save time the HPI should include all pertinent information from other sections of the history, which include PMHx, PSHx, SoHx, FmHx. These other sections are not mentioned again during the oral presentation. As students gain more knowledge, the review of systems gets smaller during the presentation. But there might be cases in which the symptoms of that section may be significant enough to be a second chief complaint as well. Medications and allergies should also be mentioned during the oral presentation.
The summary statement should contain two sentences. 

1. Chief complaint and the HPI
2. Include important signs, symptoms, physical findings, and labs

In the assessment and plan, the student should include the life-threatening problems first, then their etiology, and finally what labs or studies are needed.

The key principles in EM when getting a history is knowing the chief complaint, drawing a differential diagnosis BEFORE seeing the patient, acquiring pertinent data, analyzing it, narrowing the differential diagnosis, and presenting it in a succinct manner. 

The article is worth a look and don't forget to look at the Supplement Material, where examples are given.
 
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)

Reference
Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008 Jul;15(7):683-7. Pubmed . .

Javier Benítez, M.D. 

Trick of the Trade: Oral naloxone for opioid-induced constipation

Opioids are amazingly effective for pain control. Patients on chronic opioids, however, often struggle with constipation. These patients may fail supportive treatment with enemas and laxatives.

Trick of the Trade:
Oral naloxone

Interestingly, there are minimal systemic effects with oral naloxone. So, constipation can be directly targeted without causing systemic opioid withdrawal. Published case series reports show a variable range of therapeutic doses, ranging from 0.1-20 mg of oral naloxone. One series quoted no effectiveness under 1.5 mg. Generally 2 mg PO is a good starting point. Then titrate up slowly to achieve the laxative effect to minimize any systemic absorption.

FYI, you need to use the IV preparation, because no PO formulation exists.

Alternatively per Bryan Hayes (@PharmERToxGuy), you can also use methylnaltrexone, which also is a mu-receptor antagonist. It is dosed 8-12 mg (0.15 mg/kg) subcutaneously.

Thanks to Dr. Graham Walker (Kaiser San Francisco) and Sarah Burkart (PA at Univ of Cincinnati) for sharing this great tip!


Reference
Holzer P. Non-analgesic effects of opioids: Management of opioid-induced constipation by peripheral opioid receptor antagonists: prevention or withdrawal? Curr Pharm Des. 2012 Jun 28. [Epub ahead of print] Pubmed

Leppert W. The role of opioid receptor antagonists in the treatment of opioid-induced constipation: a review. Adv Ther. 2010 Oct;27(10):714-30. Pubmed .

Meissner W, Schmidt U, Hartmann M, Kath R, Reinhart K. Oral naloxone reverses opioid-associated constipation. Pain. 2000 Jan;84(1):105-9. Pubmed .

Technology is constantly advancing.  New tools arrive on the scene each year, and often we don't know whether to ignore them or incorporate them into our teaching.  The slideshow below is a compilation of 100 tools that can be used help our students understand content. Take a look and let me know what tools you use in the classroom. How do you determine whether they're tools or gimmicks?

Top 100 Tools for Learning 2011 from Jane Hart

Peeing into the wind? Urine drug screens, part 2 (opiates)

Apart from benzodiazepines, the opiate urine drug screen (UDS) is probably the most frequently utilized and misunderstood.

BACKGROUND
For a brief history of the UDS and a review of the test for benzodiazepines, check out part 1 of our two-part series.

OBJECTIVE
To properly interpret the UDS for opiates.

First, a couple of prerequisites... 

1) Opiate vs. Opioid

• These two terms are often used interchangeably and really shouldn't be.
• Think of it like this: 'Opioid' is the broad category name while 'opiate' simply refers to the naturally occurring opioids. The term 'opioid' encompasses opiates, semi-synthetic, and synthetic agents. The chart below gives a few examples of each.

2) Forgive me in advance for the structures, but I think it's important to understand why a drug may or may not show up on the UDS. I can't get rid of the chemist in me... 

• The point here isn't to analyze structures, but simply to see the similarities between morphine, heroin, and oxycodone. 
• Oxycodone, a semi-synthetic, is similar to morphine.
• Methadone, a synthetic, has a completely unrelated structure.

LEARNING POINTS

1. Notice the name of the UDS next time you order one. It is opiates (not opioids).
2. The test was designed to look for heroin (technically a semi-synthetic) via its metabolite, 6-monacetyl morphine. It also picks up morphine and codeine.
3. The test does not specifically look for oxycodone, hydromorphone, hydrocodone, etc. They can trigger a positive result due to their structural similarities, but not in every case. Therefore, a negative result doesn't rule out use of these common drugs of abuse.
4. Synthetics will never cross-react with the opiate UDS. They are too structurally dissimilar. That's why we have a separate test for methadone.

BOTTOM LINE
A negative result doesn't rule out opioid ingestion and a positive result only guarantees that heroin, morphine, or codeine is present. Like the benzo screen... not very helpful, in my humble opinion.

An Introduction to Medical Photography

I've always been a bit of a photobug.  I blame my grandmother who gave me my first camera when I was just a young kid.  Back in those days, we had this stuff called film.  The pictures were unpredictable and expensive, so I only took pictures of things I felt were important.  Fast forward 20 years, and the technology is incredible.  Digital photography is everywhere!  Cameras, phones, and maybe even glasses soon.

With the explosion in technology, it's very easy to take pictures of clinically relevant cases.  Images are a great teaching tool, but you need to get the right picture.  A few years ago, I attended the SAEM workshop on medical photography taught by Dr. Jason Thurman.  The course is great and if you have the chance to attend, I highly recommend it.  Here are some pearls I gleaned from their teaching as well as some additional hints to improve your skills.

1. It all starts with consent.  Like any procedure, to take a picture for educational purposes, you need to obtain consent.  This is likely to be institution specific.  Check with you institution to determine if you need an additional form.

2. What equipment do you need? These days, the quality of camera phones has improved dramatically.  That being said, dedicated cameras still have more functionality.  Digital SLRs offer the greatest functionality, but also cost a significant amount.  My advice would be to start small and if you think this is for you, move up to a dSLR.

3. Know the basics

Exposure: The amount of light that hits the sensor.  In photography this is controlled by the aperture and shutter speed.  These controls have a reciprocal relationship.

Shutter Speed: Simple; the amount of time that the shutter is open, expressed as a fraction of a second (1/60, 1/90).  Slow shutter speeds mean blurred motion if the subject is active.

Aperture: The opening in the lens that allows light through, expressed as the f-stop number; like gauge: bigger number = smaller opening.  Aperture is REALLY important because it controls the depth of field, which is basically the amount of the scene that is in focus. The smaller the aperture, the greater the depth of field.  This comes into play when taking close up or macro photos (like the eye above).  The closer to an object you are, the narrower the depth of field becomes.  Since you'll have to use a small aperture (f16 or smaller) your shutter speed will likely be slow, hence, you'll need a flash.

Gray World Assumption: All camera light meters try to make the detected scene 18% gray based on some light physics.  Because of this, scenes that are dark or bright end up messing up the exposure. (Think about the last time you tried to take a picture in bright sunlight or snow).  To compensate for this, watch the sensor and adjust the f-stop + or - one stop.  Fortunately with digital photography, we can view the pictures and make the adjustments on the fly (burned up a lot of good film trying to master this technique)

Lighting: There are 3 types of lighting: axial, texture, and flat.


Axial lighting involves holding the flash parallel to the barrel of the lens.  This reduces harsh shadows that might be created if the flash was placed in the shoe.  The image of the eye above was taken using axial light

Textural lighting adds dimension to an image by placed the light source at a 30-45 degree angle off to the side.

Image of a child with chicken pox taken using texture lighting

Flat Lighting produces the most accurate color.  It's accomplished by placing the flash on the side of the barrel or using a special flash called a ring flash.

Image of erythema migrans taken using a ring flash to produce flat lighting

4. Control the background: remove any distractions! (These, incidentally, can be an identifier)  Things like jewelry, tattoos, clothing all take away from image quality.  Place the body part in question onto a solid clean background (leftover surgical towels work AWESOME for this).  If possible, add a ruler to demonstrate scale.

Get Close, control the background, and use a scale

5. Get the right views: Think like a radiologist.  If photographing the face, get an AP, lateral, and oblique.  Think similarly for the rest of the body.  Don't be afraid to get a standard shot and then zoom in to focus on the pathology.

Now get out there, take a camera, take lots of pictures, share them, and Vive le FOAMe
Google +1

Paucis Verbis: CHF likelihood ratios

A 50 y/o man with a history of CHF and COPD is brought in by ambulance in severe respiratory distress. He is sitting upright with a RR 30 and O2 saturation of 79% on room air.

Is this a CHF or COPD exacerbation?

This is a common dilemma faced in the ED. Fortunately there are likelihood ratios to help you risk stratify using a Bayes nomogram.

Note that the first table below (McCullough et al) enrolled ED patients WITH a known history of asthma or COPD. For the second table from JAMA (Wang et al), summative LRs for BNP are provided in ED patients with or without a history of asthma/COPD.

In the end, the most helpful positive findings which help you predict a CHF exacerbation causing dyspnea are (in descending order of LR):

• Exam: S3 heart sound
• CXR: Pulmonary edema
• Initial clinical judgment  
• CXR: Cardiomegaly 
• EKG: atrial fibrillation
• CXR: Pleural effusion
• EKG: Ischemic ST-T changes  
• Exam: Jugular venous distension (JVD)
• History of atrial fibrillation 
• Lab: BNP ≥ 100 pg/mL 
• EKG: Q waves 

Thanks to Dr. Daniel Kievlan (UCSF-SFGH resident) for the idea for this PV card.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

References

McCullough PA, Hollander JE, Nowak RM, et al; BNP Multinational Study Investigators. Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department. Acad Emerg Med. 2003 Mar;10(3):198-204. PubMed PMID: 12615582. Pubmed .


Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294(15):1944-56. PMID: 16234501. Pubmed . 

Filter it: Keeping up with digital information overload

I haven’t found a way of keeping up with all the information out there, even with textbook reading. I don’t know if there is way.

Tools:

• Blogs RSS feeds: Google reader (http://www.google.com/reader)
• Podcasts: Downcast app (www.downcastapp.com)
• Stay in touch, network, and have instant discussions: Twitter, Google+

The only way that the content in these resources are relevant to me is after having a good foundation with textbook reading and reading journal articles. This is Seth Trueger (@MDAware) take on the cautionary use of social media.

I used to listen to podcasts in my car mostly on the way to work and on the way back (Always pay attention to the road). I read new blog posts (especially the short ones) while on breaks, waiting in line, etc. I use freemergencytalks.net by Joe Lex for specific lectures, mostly on patient-centered topics to see how I can improve my practice. 

I am very, very selective. My selection process:

• Who is the author?
• Is this up to date?
• Is this relevant to my practice? 
• Is it relatively short? 

If a posts is really long and it’s an essay on everything on that has to do with topic I don’t read it, I just go to the textbook. I love posts and podcasts that deal with a specific question, is conversational, casual, yet informative.

Other resources about filtering which are worth looking at:

• Information overload (Life In The Fast Lane)- examples of failure to filter 
• How to follow posts via RSS Feeds on the iPad (EMCrit)
• A med student's take on EM blogs and podcasts (ShortCoatsInEM)
• A master list of EM blogs and podcasts (Life in the Fast Lane)

Here are some of the top resources that I filter through: 

• Academic Life in Emergency Medicine
• EMBasic 
• EMCrit
• EM Literature of Note
• ERCast
• High Quality Medical Education (hqmeded)
• Life in the Fast Lane
• Prehospital Med
• Univ of Maryland EKG videos (ekgumem)

The key for me is I know where to go when I have a specific question that needs to be answered. I filter the information, make sure I have a good knowledge background, and have fun. I hope this helps. 
_____________________________

Lisa B. Marshall on communication overload: Although she is commercially sponsored (I have no affiliation), I think she gives good, and succinct advice. (Part 1, Part 2)

Trick of the Trade: Alternative to Word catheter for Bartholin abscess

Word catheter

Bartholin abscesses are challenging to manage, partly because of Word catheter insertion. Sometimes, the space is not large enough (unable to fit the catheter) or too large (catheter falls out). How else can you "pack" the abscess space?

Trick of the Trade:
Jacobi rubber ring

This trick nicely piggy-backs with last week's Trick of the Trade on incision and loop drainage. Published in the American Journal of EM, Gennis et al present their successes with their 8-French rubber tube, threaded with suture material. Kushnir et al discuss their using butterfly tubing instead of a rubber tube to create a loop. Anyone have experience with these techniques (or a version of)?

Images from AJEM article

Thanks to Dr. Marianne Haughey (Jacobi Medical Center) for telling me about this.

Reference
Kushnir VA, Mosquera C. Novel technique for management of Bartholin gland cysts and abscesses. J Emerg Med. 2009 May;36(4):388-90. Pubmed .

Gennis P, Li SF, Provataris J, Shahabuddin S, Schachtel A, Lee E, Bobby P. Jacobi ring catheter treatment of Bartholin's abscesses. Am J Emerg Med. 2005 May;23(3):414-5. Pubmed .

Peeing into the wind? Urine drug screens, part 1 (benzodiazepines)

Let’s be honest.

When was the last time results from the urine drug screen (UDS) changed your management plan?

Many times it takes hours for the patient to give the urine sample anyway. And, with all of the false positives out there, how do we know what the heck the result is actually telling us?

OBJECTIVE 
Today’s post will help you properly interpret the UDS, particularly focusing benzodiazepines.

Introduction:
The original UDS was termed the NIDA-5 (amphetamines, cannabinoids, cocaine, opiates, and phencyclidine) because they are the five drugs that were recommended by the National Institute on Drug Abuse (NIDA) for drug screening of federal employees back in the late 1980s. Drug-screening immunoassays are also frequently done for barbiturates and benzodiazepines and less frequently for methadone.

That has to raise some caution flags right off the bat! This test was not designed for Emergency Departments or hospitals for that matter. It was developed to screen federal employees. The fact that we have made it part of our standard practice affords various limitations.

In general, the qualitative UDS for each drug is looking for a particular structure. If the immunoassay identifies that structure (or one similar), it will trigger the test positive. Let's take a closer look at the test for benzos.

Benzodiazepines:
Benzodiazepines are pretty popular. In the U.S., alprazolam, clonazepam, lorazepam, and diazepam are among the most commonly prescribed medications in the outpatient setting. Here are the important points regarding this test:

1. Most benzo screens look for oxazepam. If you're wondering how this could possibly be helpful since few patients are on oxazepam, you're not alone. However, diazepam and chlordiazepoxide both are metabolized to oxazepam. So, by looking for oxazepam, you actually pick up three benzos in one.
2. The test does not specifically look for alprazolam, clonazepam, lorazepam (or many others). Therefore, a negative result does not necessarily rule out use of these agents.
3. The tricky part is that benzos vary in reactivity and potency and can trigger a positive result due to cross-reactivity.

BOTTOM LINE
A negative result doesn't rule out benzodiazepine ingestion and a positive result only guarantees that oxazepam, diazepam, or chlordiazepoxide is present. Not very helpful, in my humble opinion.

Next time we'll fully explore the opiate screen. Stay tuned...

Hack Your Education

Can you learn medicine in just 1 year?  Unlikely, but if it's possible to cover the content of a MIT computer science degree in 1 year, then anything is possible.  In this talk from TEDx Eastside Prep, Scott Young, a self described "speed reading, vegetarian, holistic learning, productivity hacking, recent university graduate," discusses his views on the future of learning and how it will be students, not institutions, who drive the disruptive changes forward.  Watch and enjoy!

Paucis Verbis: Does this adult patient need blood cultures?

Do you order blood cultures for all your ED patients with a fever? Obviously no. What's your decision making process on ordering this test? There are really no findings or tests with high specificity (rules-IN bacteremia), except interestingly "shaking chills". Notice almost all the criteria listed below approach a likelihood ratio (LR) of 1.0. Two prediction rules do exist, however, to help you virtually rule-OUT bacteremia:

• SIRS
• Shapiro prediction rule

The list of LRs also will be helpful to show learners in the ED that an isolated serum WBC number is useless risk-stratifier.

Patient case:
A 55 y/o man with a PMH of hypertension presents with a community-acquired pneumonia on CXR, no fevers, no chills, no vomiting.

• Temperature 37.8 C, BP 160/90, HR 100, RR 16, Sat 100% RA
• Serum WBC 20K (no bands)
• Platelets 300K
• Creatinine 1.1 mg/dL

What is the patient's pre-test and post-test probability for having bacteremia? Use these helpful stats from the Rational Clinical Examination series from JAMA.

Answer to patient case:

• Start with 7% pretest probability for bacteremia with a community acquired pneumonia.
• Using the clinical prediction rules, the WBC 20K and HR 100 bpm are criteria for SIRS but do not fulfill the Shapiro prediction criteria. LR = 1.8 * 0.08 = 0.144. Post-test probability for bacteremia = 0.06%. 
• If the patient had instead a normal HR of 80 bpm, both the SIRS and Shapiro criteria would have been negative. LR = 0.09 * 0.08 = 0.0072. Post-test probability for bacteremia = << 0.1%.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

This discussion doesn't address WHETHER we should get blood cultures despite a risk for bacteremia in the setting of uncomplicated pneumonia receiving IV antibiotics or pyolenephritis with a pending urine culture.

Reference
Coburn B, Morris AM, Tomlinson G, Detsky AS. Does this adult patient with suspected bacteremia require blood cultures? JAMA. 2012 Aug 1;308(5):502-11. Pubmed .

Shapiro NI, Wolfe RE, Wright SB, Moore R, Bates DW. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med. 2008 Oct;35(3):255-64. Pubmed .

New 2012 Berlin Definition for ARDS

The new 2012 definition for Acute Respiratory Distress Syndrome (ARDS) (published in JAMA June 2012)


According to the previous definition published in 1994 by the American-European Consensus Conference (AECC), ARDS must have the following 4 criteria:

the onset must be acute
there must be hypoxemia with PaO2/FIO2 ratio ≤ 200
there must be bilateral infiltrates on CXR
these findings cannot be

Trick of the Trade: Incision and loop drainage of abscesses

From depts.washington.edu

Why are we still teaching the traditional incision and drainage approach to simple abscess drainage? They require frequent, painful packing changes to ensure persistent drainage of retained pus.

Loop Abscess Drainage from Rob from ercast on Vimeo.

Trick of the Trade:
Incision and loop drainage (I&LD) technique

As per usual, Dr. Rob Orman (ercast) beat me to this. He already reviewed the technique on his blog in 2010. This stems from a landmark article in the Journal of Pediatric Surgery, which involves creating a persistently draining fistula at two points by using a small vascular loop, tied into a non-tensile loop.

It makes sense to extrapolate and use this technique for both pediatric and adult patients with uncomplicated abscess, especially if the patients may not follow-up for packing changes as scheduled. The added benefit is that showering is encouraged to help encourage drainage without the risk of dislodging the secured loop.

Questions:
Does anyone have experience with this that they would like to share? Particularly, what if you don't have the skinny vascular loops in your Emergency Department?

What are the follow-up instructions?
Per the Tsoraides article:

• Take a bath/shower TWICE daily for the first 3 days.
• Remove the loop in 7-10 days (when the drainage stops and the overlying cellulitis resolves)

VessiLoop Presentation from V. Bonales, M.D.

Reference
Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010 Mar;45(3):606-9. Pubmed .

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

Paucis Verbis: Overanticoagulation and supratherapeutic INR

I find it amazing that I know more non-emergency physicians virtually in the social media world rather than in person. Primarily through Twitter, I follow and am followed by medical educators from various specialties. If you haven't joined Twitter yet, I think it might be time. There is a whole world of collaboration and conversation going on in this virtual community, which crosses specialties and geography.

Last week, Dr. Javier Benítez (@jvrbntz) was tweeting a Question of the Day, referencing a 2010 Paucis Verbis card on overanticoagulation, which was based on the 2008 American College of Chest Physicians (ACCP) guidelines. About 8 minutes after I retweeted his question, Dr. Roy Arnold (@cholerajoe), a pulmonary/critical care physician kindly informed me that the 2012 ACCP guidelines have been out since February.

So this PV card is replacing the 2010 card with revised recommendations. To more in-depth discussion, definitely take a look at Dr. Scott Weingart's great podcast over at EMCrit. He helps to clarify holes which the 2012 ACCP guidelines don't really address such as:

• Question: What if the patient is minorly bleeding with a high INR? 
• Answer: Oral vitamin K and 15 mL/kg FFP

• Question: What if you only have the 3-factor PCC (factors II, IX, X) and not the recommended 4-factor PCC (factors II, IX, X plus factor VII)? The U.S. primarily has the 3-factor PCC. At my institution, we have bebulin.  
• Answer: If PCC is indicated, add recombinant factor VIIa or FFP to the 3-factor PCC to cover for factor VII.

2008 ACCP guidelines

New 2012 ACCP guidelines and pearls

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

[MS Word] [PDF]

See other Paucis Verbis cards.

References

Holbrook A, et al; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2

Suppl):e152S-84S. Pubmed .

Busting the myth: The 10% cephalosporin-penicillin cross-reactivity risk

To give or not to give a cephalosporin in penicillin-allergic patients?

I remember back to my days in pharmacy school when I learned that there was approximately a 10% risk of cross-reactivity, if a cephalosporin was given to a penicillin-allergic patient. They probably said something about the risk being less with 3rd and 4th generations cephalosporins, but lets be honest... who remembers anything but that magic 10%? When I started working more with physicians, I found that they also learned the same 10% rule in medical school. Well, I guess that means it’s fact, right? Not so fast!

It turns out that prior to 1980, penicillins and cephaloporins were often produced using the same fungus and the chance for contamination during the manufacturing process was high. The belief was that the beta-lactam ring similarities must be the cause. How wrong we were.

More recent studies have determined that the actual risk of cross-reactivity relates more to a side chain similarity and probably not the beta-lactam ring at all. Therefore it makes sense that if a penicillin and a cephalosporin share that particular (R-1) side-chain similarity, the risk of cross-reactivity is increased. Such is the case with amoxicillin or ampicillin with:

• 1st generation cephalosporins: cefadroxil, cefatrizine, cephalexin, cephradine
• 2nd generation cephalosporins: cefaclor, cefprozil

A new review article of 27 articles on this very topic just came out reporting:

• Overall cross-reactivity rate between cephalosporins and penicillins in patients reporting a penicillin allergy = 1%. 
• Overall cross-reactivity rate in patients with a confirmed penicillin allergy = 2.5%. 

Other key findings to note:

1. The true incidence of an allergy to penicillin in patients believed to have such allergy is <10% (it’s like we have a built in 10-fold safety factor).
2. Cross-reactivity between penicillins and MOST 1st and 2nd generation cephalosporins is negligible.
3. Cross-reactivity between penicillins and ALL 3rd and 4th generation cephalosporins is negligible.
4. If a patient has an allergy to amoxicillin or ampicillin, avoid cefadroxil, cefaclor, cefatrizine, cefprozil, cephalexin, and cephradine.

Bottom Line:

You can feel comfortable clicking past the flashing allergy alert as you enter that ceftriaxone order in your patient with a documented penicillin allergy. If the patient has an allergic reaction, it's more likely a unique allergy to that cephalosporin than any cross-reactivity with a penicillin.

References:
Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosporins in penicillin-allergic patients: A literature review. J Emerg Med. 2012;42(5):612-20. Pubmed . 

Welcome to the blog team: Bryan Hayes, PharmD

Bryan Hayes, PharmD, DABAT

Have you been read Bryan Hayes' mind-blowing pearls in the world of ED pharmacology and toxicology on Twitter (@PharmERToxGuy)? If not, you are missing out. I usually end up hitting "favorite" for all of his tweets to review again later. So for purely selfish reasons, I asked Bryan to see if he'd be willing to expand his 140 character gems on this blog. Much to my delight, he said yes!

On a quick web search, I think Bryan may be the first ED clinical pharmacist ever to have a meducation blog!

Here is a little blurb bio about Bryan:

• Clinical Assistant Professor, University of Maryland (UM) Schools of Pharmacy and Medicine
• Clinical Pharmacy Specialist, EM & Toxicology, UM Medical Center

After finishing my Pharm.D. degree (2005) and PGY-1 pharmacy practice residency (2006) in Worcester  MA, I moved down to Baltimore MD to complete a two-year Clinical Toxicology Fellowship (2008) at University of Maryland. I then joined the University of Maryland Medical Center's team as its first emergency medicine clinical pharmacist. I hold dual Clinical Assistant Professor appointments with the University of Maryland Schools of Medicine and Pharmacy and is board-certified in Clinical Toxicology. I hope to add a unique pharmacy/toxicology perspective on EM-related matters to this outstanding blog team.

Top 10 reasons why Yoda would be a terrible mentor and teacher in medicine

This is based on an article from GeekWire that lists the top ten reasons why Yoda would make a terrible teacher. Let’s see if I can make a derivation and convert these reasons as to why Yoda would make a terrible mentor/teacher in medicine.

10. Micro-manage much? 

Yoda never took into consideration the mentee’s motivations, desires, and mental states, which made for a very inefficient relationship. It also looks bad when Yoda is on Luke’s back and directing all of his moves. That level of micromanagement does not lend itself to the best situation for communication, which is a very complicated process and of essence in a learning environment.

9. Lack of transparency

It’s always important to tell your mentee what your reasoning is behind your decisions as an attending. They should learn how you go through the process of formulating answers so that they can do the same when challenged with similar problems or questions. If your reasoning is not explained, the student will never know why you arrive at a particular conclusion. Transparency also makes you more approachable.

8. The importance of goals

“Because I said so” should not really be an answer. Explain why and how the exercise/ activity/ challenge will make them better doctors. Jointly come to a decision as to what the goals of the shift are; be it seeing more patients, managing more critical care patients, working on procedures, or teaching medical students. The ultimate goal is to make of them a better doctors, take better care of patients, and be more proficient at skills. There should not be a hidden agenda. All cards should be on the table. Yoda was so secretive, and for some reason things needed to be figured out as riddles.

7. Communicate clearly

This has to overemphasized. Communication is everything. Everybody needs to be on the same page. The Geekwire article states “finding a way to minimize information friction should be job one for all mentors.” As you remember, Yoda did not communicate clearly, I mean really, who talks like that?

6. Authentic assessments

The mentor/teacher should be aware of the learner's knowledge and where that falls within the standard for that level of training. If the student hasn't met these expectations, a plan should be laid out to delineate how to get there. There should also be benchmarks to let the student know whether s/he was successful. These assessments and benchmarks were not made clear by Yoda, which I would imagine made Luke more frustrated. 

5. Authority problems
The mentee/mentor relationship is a delicate one, and all the authority should not fall on just the mentor. The relationship should be seen as a respectful collaboration going both ways. Without respect, the relationship suffers and the communication fails. Yoda was very frustrated at what appeared to be Luke’s lack of respect, but the respect did not come from Yoda either. Mutual respect leads to better communication and a conducive learning environment.  

4. Constructed learning from existing contexts
Basically Yoda did not know how to motivate Luke to learn. Criticism needs to be well directed, specific, constructive, and connected to experiences that the mentee can relate to. Sometimes criticism are more welcomed when they come from a person that the mentee can relate to culturally, chronologically, etc. The point is that there has to be some common ground beyond the mentor/mentee relationship.

3. Dispel cult auras
Mentors might be too detached from the students. When the mentee or the mentor cannot relate to each other, the learning is more difficult. I’ve heard great podcasts where the attendings sound very down to earth, and this in turn makes the students feel more comfortable to learn from them. I went to a conference where Amal Mattu was lecturing, after lecture I approached him and called him Dr. Mattu, the first thing he told was to call him Amal. After that my conversation with him felt more like I was talking to a friend even though I knew how well renown he was.   

2. Accessibility in all ways
The mentor creates a better learning environment when the mentee sees him/her as being approachable. This is much easier with technology in the present time. When we have a question, we can just go ahead and text or email someone. In contrast, Yoda was pretty inaccessible.

1. There is nothing magical about learning new things
All students should know that learning is hard, and that they need to put in a lot of work. No matter how stellar a mentor is, if the mentee does not put in the time, s/he will not get to master the skills necessary to be successful. The name of the game is repetition, there are no shortcuts. 

The mentor-mentee relationship is a very complicated one. If basic principles are followed, however, the process of learning and mentorship can be a mutually beneficial and joyful experience. Clear communication and mutual respect are the foundation in this relationship, which both parties should strive for. 

Basically, don't be Yoda.
Javier Benítez, M.D.