What's on my mind: EBM Resource

Keeping up with the EM literature is difficult, particularly when we're also trying to stay ahead of the curve in our own subspecialties (Healthcare Simulation and Medical Education in my case). Last week I was listening to Scott Weingart's EMCRIT Podcast and at the very end of the show he mentioned a new EBM resource: TheNNT.

I said to myself, what the **** is The NNT? And then Scott explained:

www.thennt.com

"The Number Need to Treat is the simplest tool to understand the true potential benefits and harms of any of the treatment or tools we use in medicine. TheNNT.com site is a free resources that uses this tool to best communicate the results of high quality evidence"

I've looked at this site and cannot wait to use it in the clinical setting when I'm taking care of patients, teaching our residents (and off service residents) and collaborating with other specialist.

I hope its useful to some of you out there and I hope the New York-based, superstar group that put together the site continue to grow it!

Are there EBM or on-line teaching resources that you love? Let us know!

Demian

The NNT group is: Jarone Lee, David Newman, Josh Quaas, Ashley Shreves, and Graham Walker, all Academic EM Physicians and rockstars in their own right.

Trick of the trade: Single digital block

Your next ED chart: Finger injury

The finger needs to be anesthetized.

Patient: "I have had this freezing before. The needles really hurt! Is there anything else less painful? "

Trick of the Trade:
A single, subcutaneous, volar-approach digital block

The traditional ring block involves two injections at the base of the finger (and a third injection if anesthetizing the thumbs and toes). A recent article adds to the literature on a non-traditional approach to the digital block - the single subcutaneous method.

Where do we inject?

Midpoint of the crease where the finger joins the palm, on the volar side.

How deep is the injection?
Subcutaneously. The anesthetic will deposit on top of the tendon sheath and infiltrate to where the digital nerves are.

How much volume?
About 2-3 cc.

Study results

How effective is this volar subcutaneous approach?
It is just as good as the traditional multiple-stick, dorsal approach. In this study at 5 minutes, 76% (28/37) patients in the single injection group were adequately anesthetised compared to 65% (22/34) patients in the traditional block (p=0.436, no statistically significant difference).

Also there were no differences in anesthesia at 10 minutes.

Is this less painful?
The self reported pain score was less, but again the difference was NOT statistically significant.

Do clinicians like this better?
Yes, the difference in Clinician Satisfaction score WAS statistically significant. In fact, many study clinicians adopted the single injection method, making recruitment of the trial subjects difficult.

What is my experience?
I really like this method since patients seem to tolerate this better. However, it does not work as well for the thumb, probably due to the dorsal branches of its digital nerves.

Other techniques described involve infiltrating the area 1-2 cm proximal to the digital-palmar crease similarly. I find they all work well for me.

What are others' experiences?
Converts swear by this. Some even use this to anesthetise toes!

Bottom line:
A single volar subcutaneous injection is efficacious and may be less painful for finger anesthesia.

Reference:
Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M (2010). Digital anaesthesia: one injection or two? Emergency medicine journal: EMJ, 27 (7), 533-6 PMID: 20360491
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Tips to building authenticity into your talk

For lecturers, much focus is placed on improving the visual display and factual content of your talk.

• Keep slides simple
• Add relevant, non-extraneous images
• Avoid cramming too much information into your talk

Go to the podcast link

On the Duarte Design website, Nancy Duarte interviews Nick Morgan, the author of "Trust Me: Four Steps to Authenticity and Charisma". In the 18-minute podcast, the author gave some pearls which I haven't really heard before.

For instance as a speaker, you should be focused on your non-verbal presence. How can you frame your actions and presence to help convey your information better as something authentic and worth learning about? In brief, imagine that you are about to meet up with your best friend. Your posture and demeanor will change subconsciously.

Another issue that they discuss deals with the issue of being rehearsed versus being spontaneous. Being over-prepared makes you look stilted and dry. Being overly-spontaneous makes you look unsure and unprofessional. I constantly struggle with finding the right balance. I've been all over the spectrum over my career and have finally settled a little more towards the spontaneous end. Where are you on the spectrum?

The author also gives some practical tips about establishing your speaking style and general approach to engaging the audience. Take a quick listen to the 18-minute podcast.

ACEP Scientific Assembly (Sept 28-Oct 1)

The American College of Emergency Physicians annual Scientific Assembly starts tomorrow officially but several pre-day events start today in Las Vegas! The CORD Medical Education Research Certification (MERC) longitudinal course is being held today.

Introduction to Qualitative Data Collection Methods 

Instructor: Ilene Harris, PhD

Questionnaire Design and Survey Research 

Instructor: Carol Hodgson, PhD 

I will try to tweet (@M_Lin) some high-yield learning points on the area of Educational Research from the all-day session.

If you want to read tweets from people attending the ACEP Scientific Assembly, check out this website (wthashtag.com/Sa10), which tracks all posts which have the #SA10 hashtag designation. (You don't need a Twitter account to view this website.)

Sharing my Paucis Verbis cards using Dropbox

After much discussion in a prior post about the pros and cons of Evernote, Google Docs, and Dropbox, I think all of these applications are great for reading PDFs on the go. These are all examples of cloud computing. Deciding which you like better might depend on what side-features you like:

• Ability to edit on mobile phones
• Your preference of graphic interface layout
• Searchability
• Geo-location tagging
• How many people you want to collaborate with

I initially thought to share my Paucis Verbis cards by sharing my Evernote folder publically. Unfortunately, this only works for the web-version of your Evernote account and not for the iPhone app. Dropbox was mentioned several times because the shared files also appear on various mobile phone platforms.

So I am also uploading my Paucis Verbis cards to a PV Dropbox folder on a weekly basis starting now, in addition to Evernote. Unfortunately, I have to manually enter your email address to share my Dropbox folder. So if you contact me or leave your email in the comments box below, I'll share my folder with you. I think the cards should also transfer to your mobile device.

My email: Michelle.Lin@emergency.ucsf.edu

Tweet me: M_Lin

5 rules for creating great Powerpoint presentations

As much as people talk about "Death by Powerpoint", many of us still use Powerpoint despite its many shortcomings. So how can we make our Powerpoint talks better?

This video reviews 5 great rules to live by. Interestingly, this dynamic video was built using Powerpoint by Nancy Duarte from Duarte Design. Of note, Duarte Design was the company behind the stunning slides which Al Gore used to present his compelling talk on An Inconvenient Truth.

1. Treat your audience like king.
2. Spread ideas and move people.
3. Help them see what you are saying.
4. Practice design, not decoration.
5. Cultivate healthy relationships.

Less is more, on Powerpoint.

Trick of the Trade: Toenail splinting for ingrown toenails

It is 4 a.m.

You pick up a chart.

Toe pain.

Thinking this could be an easy injury, you walk over to the patient, only to discover: bilateral ingrown toenails. Your heart sinks. In your head, you are thinking: Lateral nail resection? Nail removal? This could take a while.

Is there a less invasive method for treating an ingrown toenail?

Trick of the Trade: Toenail splinting

The referenced article describes splinting the toenail, essentially lifting the offending edge of the toenail so subsequent growth does not push into the tissue.

1. Anesthetize the toe either by topical anesthetic or by nerve blocks (not always necessary for mild cases).
2. Excise nail sulcus using the tip of a curved hemostat to provide space. See photo above.
3. Roll a 2-3 cm wisp of cotton saturated with alcohol to form a cylinder.
4. Tuck the cotton into the nail sulcus, gently tucking it under the lateral free edge of the nail. This will keep the nail lifted during subsequent growth. Can also use a curved hemostat for this step.
5. Patients should keep splints on for up to 3 months until the offending corner of nail grows past the distal edge of the lateral nail fold. Do not trim nails. Patients can repeat this process if the cotton falls out.

Variations:

Steri-strips or dental floss can also be used.

What I found:

This works great. Most times patients do not need nerve blocks and tolerate it well. I know colleagues who use this technique on their own toes!

Reference

Pottie K, Dempsey M, & Czarnowski C (2003). Practice tips. Toenail splinting. Canadian family physician Medecin de famille canadien, 49, 1451-3 PMID: 14649982

Free PDF download of article

New guest blogger: Dr. Stella Yiu!

Welcome to our new superstar, educator-extraordinaire, guest blogger, Dr. Stella Yiu. Today's post is her first (of hopefully many).

After graduating residency from the University of Ottawa, Stella has been working as a staff physician at University Health Network in Toronto. She is involved in curriculum design in undergraduate emergency medicine clerkship at the University of Toronto.

Welcome, Stella!

Sharing my Paucis Verbis cards on Evernote

Did you know that Evernote allows you to share notebooks? I already have a notebook built for my Paucis Verbis Cards, so that I can access them on my iPhone in the ED on the go. I thought I would share with you, in case you also use Evernote. That way whenever I post a new PV card, your Evernote account should also get my updates.

Instructions:

(click to enlarge)

1. From your laptop/desktop, go to this URL link: http://www.evernote.com/pub/michelleclin/paucisverbis
2. On the upper right corner of the screen (red arrow), click on the tiny link "Link to My Account"

Don't use Evernote? You might think about trying it out. It's free. Here's my first introduction to Evernote.

What is "contextualizing" patient care?

Medicine is as much about Science as it is about Art.

This is no better illustrated than an educational intervention study about "contextualizing" patient care, published in JAMA.

What is contextualization?

It is the "process of identifying individual patient circumstances (their context) and, if necessary, modifying the plan of care to accommodate those circumstances". In other words, this is care beyond the evidence-based guidelines, beyond standardized quality measures, and beyond the checklists.

• What if the patient hasn't been able to afford the more expensive blood pressure medications they've been prescribed by their primary care physician?
• What if your patient is marginally housed with poor access to food?
• What if your patient gets confused easily when reading pill bottles?
• What if your patient has no access to care?

These are real concerns in the Emergency Department setting. In contrast, contextualized patient care really isn't taught in any formal fashion in medical school or residency. It's learned on the job.

Study question

Can a 4-hour educational course on contextualizing patient care improve a 4th year medical student's ability to detect and act on contextual "red flags" in standardized patient exams?

Study methodology

Students at 2 sites were quasi-randomized into the control (no educational course) versus study group (received educational course). Students from both groups participated in an end-of-rotation session where they each assessed 4 standardized patients.

There were 4 patient cases:

1. 43 y/o man with recent persistent asthma symptoms despite being prescribed a low dose of a high-cost, brand-name, inhaled glucocorticoid
2. 47 y/o woman presenting for preop assessment of hip replacement reports mild hypertension and being overweight
3. 59 y/o man with diabetes presents with 2 presyncopal episodes after previous physician increased insulin dosage
4. 72 y/o man with unexplained weight loss

Each case had 4 variants:

1. Baseline case
2. Had a contextual red flag
3. Had a biomedical red flag
4. Had both a contextual and biomedical red flag

For instance, in the case of the 59 y/o diabetic man with presyncopal symptoms:

• Contextual red flag: Confuses dosages and says "It's hard for me to keep numbers straight".
• Biomedical red flag: "I felt some pounding in my chest when it happened."
• Baseline error: No adjustment of insulin dosing or discussion of dietary change to prevent hypoglycmemia
• Contextual error: No discussion of obstacles to self-care in patient with cognitive disabilities which impair his ability to administer his own insulin. He had recently left a community where he had assistance.
• Biomedical error: No EKG, Holter monitor, or stress test ordered in patient with symptoms of arrhythmia.

Results

Students in the intervention group (90%) were more likely to probe for contextual issues in the standardized patient encounters than the control group students (62%). The intervention students were also more likely to develop appropriately revised treatment plans for patients with contextual issues (69%) compared to the control group students (22%). As expected there was no difference between the two groups in the rate of probing and treatment plan development for patients with biomedial issues.

Limitation

As with many prospective educational studies, there was a large attrition rate. Of the 189 of who consented to participate, only 124 remained to participate in the standardized patient encounters at the end of the 4 weeks. The authors appropriately conducted a sensitivity analysis to determine the worst-case scenario, which assumed that the students in the intervention group did NOT benefit from the educational intervention. Even with this scenario, recalculations still demonstrated statistically significant benefit from the intervention:

• Probing contextual red flag: Control (60%), Intervention (82%)
• Planning contextually-appropriate treatment: Control (22%), Intervention (55%)

Conclusion

This study demonstrates that teaching contextualized patient care is possible and that a 4-hour course is effective in changing student behavior.

Schwartz A, Weiner SJ, Harris IB, & Binns-Calvey A (2010). An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients. JAMA : the journal of the American Medical Association, 304 (11), 1191-7 PMID: 20841532

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Paucis Verbis card: When murmurs need echo evaluation

Have you been in a situation where you are the first to detect a cardiac murmur in a patient? If you are hearing it in a busy, loud Emergency Department, I find that it's at least a grade III.

Should you order an echocardiogram for further outpatient evaluation? It depends on the grade and characteristic of the murmur, in addition to the patient's symptoms. For instance, all diastolic murmurs require an echo. There is a useful ACC/AHA algorithm which helps you decide.

Thanks to Amy Kinard, an Emergency RN and aspiring Family Nurse Practitioner, for drafting this useful Paucis Verbis card for me during her studies. Keep the great ideas coming, everyone!

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Bonow, R., Carabello, B., Chatterjee, K., et al. (2008). 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Circulation, 118 (15) DOI: 10.1161/CIRCULATIONAHA.108.190748

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CORD Academic Assembly schedule is out!

The preliminary schedule for the upcoming 2011 CORD meeting is available to view. The theme is "Residency 2.0" -- Web 2.0 in medical education.

I downloaded and posted on Google Docs in spreadsheet format. Yours truly will be talking on March 3, 2011 in the annual session on Medical Education Journal Club, under the CDEM track. Dr. Sorabh Khandelwal and I will be reviewing the highest impact education articles from 2010 in rapid-fire form.

View the 2011 CORD Academic Assembly agenda in Google Docs format.

FYI, if you are a senior EM resident interested in academics, EMRA has a $500 "Faculty Development Scholarship for Residents" scholarship available to help fund your way there. It's the ideal learning/ networking environment with high-yield topics, big-name speakers, and just a small enough conference to actually get to meet people.

Trick of the trade: I got ultrasound gel in my eye!

Bedside ultrasonography is increasingly being used in the ED to examine the eye. For instance, it can be used to detect a retinal detachment, vitreous hemorrhage, and high intracranial pressure. The technique involves applying ultrasound gel on the patient's closed eyelid. A generous amount of gel should be used to minimize the amount of direct pressure applied on the patient's eye by the ultrasound probe.

Sometimes, however, no matter how careful you and the patient are, some gel accidentally contacts the eye itself.

Trick of the Trade:

Apply a transparent tegaderm dressing over the patient's closed eyelid. This provides an addition barrier between the gel and the patient's eye without compromising ultrasound image quality.

The trade-off with this trick, I find, is that while the patient's skin doesn't contact the gel, the removal of the tegaderm adhesive may peel off some eye makeup or a few eyelashes! Pick your poison.

Roth, K., & Gafni-Pappas, G. (2010). Unique Method of Ocular Ultrasound Using Transparent Dressings. The Journal of Emergency Medicine DOI: 10.1016/j.jemermed.2009.10.020

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Do you belong to a listserv? My favorites

An email mailing list (or listserv) is a great way to communicate with a large group of people. Once you subscribe to a mailing list, an email sent to a single, common email address will be distributed to everyone who is subscribed to the list. You can find lists for nearly everything and anything!

There are a multitude of lists for various medical specialties. These lists unite people from all over the country (and world) from various practice backgrounds such as academic/community medical centers to rural hospitals/clinics. We are all connected by the power of the internet. The lists are a great way to generate discussion on clinical cases, the newest literature and the experiences of the list's members.

Below are some of my favorite lists:

EMED-L: Emergency Medicine
http://listsrv.ucsf.edu/cgi-bin/wa?A0=EMED-L

Ped-EM-L: Pediatric Emergency Medicine
http://listserv.brown.edu/archives/cgi-bin/wa?A0=PED-EM-L

CCM-L: Critical Care Medicine
http://www.ccm-l.org/list.html

Trauma-List: Trauma/Critical Care
http://www.trauma.org/archive/traumalist.html

PICUList: Pediatric Critical Care
http://pedsccm.org/Piculist.php

Pediatric Sedation Listserv
http://mailman.listserve.com/listmanager/listinfo/pediatric_sedation

Does anyone else have a favorite list?

New guest blogger: Fred Wu!

Welcome to our new superstar guest blogger, Fred Wu. Today's post is his first (of hopefully many).

Fred is the Lead PA in the Department of Emergency Medicine at Kaweah Delta Medical Center in Visalia, CA. After graduating in 2004, he has been practicing community emergency medicine in Central California. His interests include prehospital care and wilderness medicine, with an education emphasis in both. He also coordinates PA/NP training in the department as well as an EM lecture series, which hosts guest speakers from across the country.

I've learned that the key to success in life and work is to surround yourself with great people. With Fred joining our blogging team at Academic Life in EM, I'm one step closer to success.

Article review: EM consensus response to duty hour recommendations

"The problem with being on call every other night is that you miss half the cases!"

Excessive resident fatigue was just par for training in the old days of Medicine before duty hours came into effect, thanks to the ACGME. In 2008, the Institute of Medicine (IOM) provided more restrictive duty-hour recommendations. Key leaders in Emergency Medicine convened to develop a consensus response to these IOM recommendations. The following is a summary of the response, published in Journal of Emergency Medicine.

Here are the key 2008 duty-hour recommendations, borrowed from the IOM website:

(click to enlarge)

In general, the EM consensus responses to these recommendations took into account a need for "a balance between patient safety, resident wellness, and training." I'm listing some of the more interesting responses:

IOM Recommendation:

"Programs should design resident schedules using the following parameters: Scheduled continuous duty periods must not exceed 16 h unless a 5-h uninterrupted continuous sleep period is provided between 10:00 p.m. and 8:00 a.m. This period must be free from all work and call, and used by the resident for sleep in a safe and sleep-conducive environment. The 5-h period for sleep must count toward total weekly duty hour limits. After the protected sleep period, a resident may continue the extended duty period up to a total of 30 h, including any previous work time and the sleep period. Residents should not admit new patients after 16 h during an extended duty period."

EM Response:

"If the current system for resident overnight coverage of inpatient services is maintained, the recommendations of a 5-h ‘‘nap gap’’ may lead to a backlog of patients waiting to be admitted and hence increased patient crowding in the emergency department (ED). Increased patient boarding has been shown to decrease patient safety. Requiring a 5-h sleep period would necessitate additional patient care handovers, which has patient safety issues. Finally, implementation of a nap policy would be contrary to the recommendations from another IOM report on emergency care in America."

My reading between the lines:

The "nap gap" concept will NOT work. Inpatient services should get rid of call and convert to a shift-based system, similar to the ED.

_______________________________________

IOM Recommendation:

"Programs should design resident schedules using the following parameters: Night float or night-shift duty must not exceed four consecutive nights and must be followed by a minimum of 48 continuous hours off duty after three or four consecutive nights."

EM Response:

"Studies from EM and sleep experts show that limiting the number of night shifts to a maximum of three to four may not provide the most beneficial sleep schedule. Flexibility is the most important consideration for program directors and resident sleep schedules."

My reading between the lines:

Bad idea. There isn't any literature stating that 4 nights, followed by 2 days off is better than, for instance, 5 nights and 3 days off. As someone who used to make the resident and faculty schedules, I can state for a fact -- flexibility is key. The more rules and restrictions you put on making the shift schedule, the more disruption you put on everyone's schedule. And I mean -- everyone. For instance, which is worse on an individual?

• Option #1: Work 4 nights in a row, 2 days off, 1 night, 24 hours off, and then followed by 4 days shifts
• Option #2: Work 5 nights in a row, 3 days off, then followed by 4 day shifts

What HAS been proven in the literature is that longer blocks of night shifts, followed by longer blocks of day shifts, is better tolerated in EM.

Take a look at this article. There are more excellent points made by my friend Dr. Mary Jo Wagner (first author) and her colleagues. A controversial question that arises from these duty hour restrictions are that with fewer actual clinical hours worked, should residents be extending their training by another year? If so, who pays for this?

Reference
Wagner MJ, et al (2010). Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 institute of medicine resident duty hours recommendations. The Journal of emergency medicine, 39 (3), 348-55 PMID: 20634017

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Paucis Verbis card: Thrombolytic contraindications in CVA

With the recent widening of the thrombolytic window from ≤3 hours to ≤4.5 hours for ischemic strokes, I wanted to review the contraindications for thrombolytics (rtPA). To review the NIH Stroke Scale (NIHSS), go to the Paucis Verbis card on NIHSS.

Thanks to Dr. Jason Nomura for making this card and summarizing the long list of exclusion criteria. If anyone has a practical topic, algorithm, or table, please feel free to share! I'd be happy to format and upload into the PV series.

Great graphic from UCLA Stroke Center: 

(Addendum 11/4/10)

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

[MS Word] [PDF]

See other Paucis Verbis cards.

References
NINDS (1995). Tissue Plasminogen Activator for Acute Ischemic Stroke New England Journal of Medicine, 333 (24), 1581-1588 DOI: 10.1056/NEJM199512143332401

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del Zoppo, G., Saver, J., Jauch, E., Adams, H., & , . (2009). Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator: A Science Advisory From the American Heart Association/American Stroke Association Stroke, 40 (8), 2945-2948 DOI: 10.1161/STROKEAHA.109.192535

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Making your teaching points stick

Thanks to Presentation Zen's blog for highlighting Tom Wujec's short 6.5 minute video about the 3 ways that the brain creates meaning. In other words, how does your brain retain information? Tom Wujec is a known innovator in the business world, specifically on visualization and creative thinking.

You can apply this knowledge towards improving your teaching skills in both the classroom setting and clinical work environment. In the above slide, borrowed from Presentation Zen's blog, making your message or teaching point "stick" should involve:

1. Use images to clarify ideas.
2. Interact with these images to create engagement.
3. Augment memory with persistent and evolving views.

Interestingly in parallel with adult learning theories, this talk addresses 2 of 3 types of learning styles:

1. Visual learner (learn best by seeing)
2. Auditory learner (learn best by hearing)
3. Kinesthetic learner (learn best by doing)

Trick of the Trade: Burned fingertips as a clinical clue

A patient presents to your Emergency Department with altered mental status and somnolence. You don't smell alcohol on breath and you don't see needle track marks. What clinical clue points you towards cocaine or methamphetamine ingestion?

Trick of the trade:

Look for burned fingertips!

Patients who smoke crack or methamphetamines typically use a glass pipe as shown below. The glass pipes get hot and often burn the tips of people's fingers.

Crack pipe

Meth pipe

After a crack or methampethamine binge, patients often get a washed-out syndrome where their catecholamine stores are completely depleted. They sleep for hours. Often they come in this washed-out stage when they present to the ED.

New favorite blog: Wishful thinking in medical education

Wishful Thinking in Medical Education

I recently came upon this great blog by Dr. Anne Marie Cunningham, a general practitioner and Clinical Lecturer at Wales, UK. She has some really insightful posts about education, its future, and the use of new technologies. This blog has been in existence since 2008. Just as interesting are the tons of comments that she gets from a spectrum of readers. Check it out!

She is also extremely active on Twitter with over 2,000 followers (@amcunningham).

Article Review: Student documentation in the chart

Do you have medical students rotating in your Emergency Department? Are they allowed to document in the medical record?

Charting in the medical record is the cornerstone of clinical communication. You document your findings, your clinical reasoning, and management plan. The medical record allows communication amongst providers. Chart documentation is a crucial skill that every medical student should know, as stated by the Association of American Medical Colleges (AAMC).

However, there is a growing trend whereby medical students are no longer being allowed to document in the medical record. I find this alarming, because this was often how I assessed their knowledge and clinical competency. Various reasons for excluding students include:

• Medicolegal risk
• Inaccurate information
• Unsigned notes
• Inability to bill and be reimbursed

This is especially true for institutions where the medical record is electronic and not paper-based. These electronic medical records (EMR) tend to lock-out and restrict access by students.

This Academic Medicine study reports results from a 23-item survey of medical school deans in the U.S. and Canada. The response rate was 63% (79/126).

• 96% and 94% of respondents stated that 4th-year student notes should be included in the inpatient and outpatient records, respectively.

The respondents felt that a student's inability to document in the chart would have negative consequences:

• Not feeling a part of the team (96%)
• Inadequate preparation for internship (95%)
• Lack of a sense of being involved (94%)

Bottom line - Getting to the point:

Medical school deans overwhelmingly support that medical students' notes be included as part of the patient's official medical chart from an educational standpoint. Furthermore, it promotes a sense of inclusion on the medical team.

The authors advocate that governing organizations such as AAMC, the Liaison Committee for Medical Education (LCME), or the Alliance of Clinical Educators (ACE) should officially recommend that student notes be included in the patient chart.

I totally agree. It isn't like entering PGY-1 residents can magically document better now that they have just graduated from medical school. Medical students should be taught how to and be allowed to document in the chart, with appropriate guidance. The starting PGY-1 residents are already stressed out in adapting to a new system with new responsibilities. There's no need to add chart documentation to their list of things to learn!

Reference
Friedman E, Sainte M, & Fallar R (2010). Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Academic medicine : journal of the Association of American Medical Colleges, 85 (9), 1440-4 PMID: 20736671

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Paucis Verbis card: Pertussis

Bordetella pertussis

Is your Emergency Department administering Tdap immunization boosters instead of dT boosters? Patients with wounds are getting updated not only for tetanus and diphtheria, but also now for pertussis.

Apparently there has been sharp rise in the national incidence of pertussis in 2010. The infection has been documented in both infants (underimmunized less than 3 months old) and adolescents/adults (loss of immunity after 10 years). In fact, the CDC has issued an epidemic warning in California.

How do you diagnose pertussis? What are the classic symptoms? Better yet, how do you rule-it out clinically?

You won't like the answer. It often presents like the common cold and clinical symptoms are minimally helpful in making the diagnosis. So, according to the American Academy of Pediatrics, you should treat anyone under the age of 3 months in whom you suspect pertussis. Complications from pertussis in infants include apnea, seizures, secondary pneumonia, and death. That means any with an innocent cough should be treated with azithromycin!

Take a listen to the paroxysmal cough and classic whoop:

http://www.immunizationed.org/Downloads/per.wav

The following is a meta-analysis article from JAMA on diagnosing pertussis in adolescents and adults.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Cornia PB, Hersh AL, Lipsky BA, Newman TB, & Gonzales R (2010). Does this coughing adolescent or adult patient have pertussis? JAMA : the journal of the American Medical Association, 304 (8), 890-6 PMID: 20736473

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Video lecture resources in EM

A reader, David, an Emergency Medicine resident from Sweden, recently emailed me to ask about good video lecture resources in Emergency Medicine. I thought I would poll everyone and crowdsource out this question.

Thus far, we came up with the following:

1. All LA Conference (Free)

• This site hosts lectures, which were held at joint conferences amongst the Los Angeles EM residency programs.
• This site is hosted under EM:RAP.

2. CMEdownload (One-time $350 subscription)

• This site is run by my friend, Dr. Diku Mandavia. This site has recorded over 2,000 lectures from various national conferences.

3. Emedhome ($79/year)

• This site was one of the original online EM educational resources and is run by my friend, Dr. Rick Nunez.
• This site hosts not only video lectures, but also an "EMCast" podcast by Dr. Amal Mattu and various online articles.

4. EM:RAP TV (free)

• This site (EM Reviews And Perspectives), hosted by my friend Dr. Mel Herbert, hosts short snippets of focused clinical knowledge, in a casual format.
• Most videos are 2-10 minutes long.

5. USC Essentials ($450/yr, or $98/yr for residents and medical students)

• This site hosts lectures from USC's popular Essentials CME course, dating back to 2006.
• Hosted under EM:RAP.

Any other good video-based resources in Emergency Medicine?

Disclaimer: I have no financial ties with any of these groups.

Trick of the Trade: "Pour some sugar on me"

Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits.

How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach.

Trick of the Trade: Pour some sugar on it.

Def Leppard is right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. The rectal prolapse often reduces spontaneously or with gentle manual pressure.

References

Ramanujam PS, Venkatesh KS. Management of acute incarcerated rectal prolapse. Dis Colon Rectum. Dec 1992;35(12):1154-6.

Coburn WM III, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. Sep 1997;30(3):347-9.