Paucis Verbis card: Algorithm for suspected pertussis in pediatrics

To treat for pertussis or not? 

In the setting of the current pertussis epidemic in California, each kid with a cough sparks constant debate about whether to treat with azithromycin or not. Finally, thanks to my friends Dr. Andi Marmor and Dr. Shon Agarwal Jain (UCSF Pediatrics faculty), there's a great algorithm to help you answer the question. I have found this algorithm extremely helpful.

You basically start by risk-stratifying by age and pertussis immunization status. For instance, if the patient is <3 months of age (or >6 months of age AND unimmunized), then follow the algorithm listed as "High Risk for Pertussis".

(click to enlarge)

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Opportunity for med students: SAEM meeting in Boston (Jun 1-5, 2011)

The Society for Academic Emergency Medicine (SAEM) holds its annual meeting at various U.S. metropolitan cities. This year, it is going to be at Boston in June 1-5, 2011.

It is a terrific conference for medical students and residents interested in EM academia. To help coordinate the huge meeting, the SAEM Program Committee is looking for 15 enthusiastic medical students to serve as volunteers.

What are the benefits?

• Waiver of your registration fee to the SAEM Annual Meeting
• Working with a Program Committee member (an academic EM faculty member)
• Learning more about the current research and educational activities in EM
• Networking with lots of academic EM faculty
• A personal letter from the Committee Chair to your Dean of Student Affairs, acknowledging your contributions.

Commitment Requirements:
1. Arrive evening of May 31 and stay through noon on June 5th.* 

2. Attend daily Program Committee meetings.

3. Complete assigned tasks, which include but are not limited to: 

• Approximately 6 hours of responsibilities per day
• Soliciting reviews
• Assisting in AV needs
• Facilitating workshops
• Being responsive and flexible to the needs of the Program Committee

Interested medical students should submit their name and contact information to the SAEM office by emailing Michelle Iniguez at MIniguez@saem.org. Please write “Medical Student Program Committee Member Annual Meeting” in the subject line and attach a very short statement of interest (<150 words) as well as an updated electronic copy of your CV. 

Application deadline: February 1, 2011

Notification of selection: February 21, 2011

* Travel and hotel will be the responsibility of the individual student; however, SAEM will provide the emails of other selected students to facilitate consolidating lodging expenses.

Tricks of the trade: Intranasal fentanyl for pediatric patients

Pediatric patients often receive inadequate pain control in the setting of orthopedic injuries. Because the child experiences fear, anxiety, and pain with needles, practitioners often shy away from ordering IV or IM pain medications. Oral agents, while easier to administer, usually provide inadequate pain control.

Trick of the Trade:

Intranasal (IN) fentanyl

Thanks to my friend Dr. Ron Dieckmann (Editor-in-Chief for PEMSoft, Chairman of Board for KidsCareEverywhere, and Pediatric Director for Valley Emergency Physicians) for his tip about intranasal fentanyl:

It is imperative that the drug be administered in a nebulized form using an atomizer device -- one half the volume in each nostril. Attach a 1 cc syringe to the end of the atomizer to administer fentanyl intranasally.

It is rapidly absorbed and provides excellent analgesia within minutes. It works just as well as IV morphine (1). If you just drop the liquid in the nose without using the atomizer, the child will swallow some of the drug, and onset and effect will be blunted significantly and titration is not possible.

The starting dose of 1.5 microgram/kg can be repeated in a dose of 0.5-1.5 microgram/kg IN in 5 minutes.  Be sure to use extreme caution in younger patients who are more susceptible to the respiratory depressant effects of all opiates; it has not been tested in children < 3 years of age at all, so I would not use in this age group. Put patients on a pulse oximeter. In the event that a child receives the drug and starts to desaturate, bag the patient, then just give naloxone 0.1 mg/kg/dose to a maximum of 2 mg intramuscularly, and the respiratory effects will be rapidly reversed.

Do you use intranasal fentanyl at your practice?

Reference
1. Borland M, Jacobs I, King B, O'Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40.

Presenting naked: TED video on "crowd accelerated innovation"

The TED curator, Chris Anderson, gives a great example of how visuals are meant to only supplement your "naked presentation". He doesn't depend on slides. He's telling a story. His visuals were built using Prezi. He tells an impactful story about the power of the internet in sharing innovation from all corners of the world. 

This got me thinking about how I really should minimize my Powerpoint slides. This is a great illustration of "less is more".

Article review: EM in medical schools

Similar to JAMA, which publishes an annual publication focusing on Medical Education, the Academic Emergency Medicine (AEM) journal just published a AEM-CORD/CDEM supplement focusing on EM education. I was fortunate to be involved with one of the papers published in this supplement.

This paper, written on behalf of the Clerkship Directors in EM (CDEM) and the Association of Academic Chairs of EM (AACEM), reviews the past, present, and future of EM in the U.S. medical school curriculum.

EM faculty members are playing an increasingly important role in both the preclinical and clinical curriculum. Our specialty teaches skills and knowledge, crucial for all medical students regardless of their eventual career choice. EM educators are a natural fit to teaching topics, such as the following:

• Basic life support (BLS)
• Advanced cardiac life support (ACLS)
• Wound care
• Splinting
• Basic procedural skills
• Simulation-based education
• Bedside ultrasonography
• Management of common emergencies

Furthermore, as medical schools are looking towards restructuring their overall curriculum to incorporate more clinical exposure from day 1, the diverse, high-volume environment of the Emergency Department (ED) makes it a perfect fit for students. Recall back to when you were a first-year medical student. How amazing would it have been to observe ED patients to reinforce your learning about pharmacology, anatomy, pathology, and heart sounds?

From an institutional standpoint, the EM clerkship fulfills many of the Liaison Committee on Medical Education (LCME) educational requirements. The LCME is the regulatory body that accredits U.S. and Canadian medical schools. The LCME recognizes that the ED provides students with an unparalleled learning opportunity. Consequently, more and more schools are making EM clerkships mandatory. In 2004, about 39% of U.S. medical schools had mandatory EM clerkships for third-year medical students. There's an ongoing CDEM study to determine the more updated numbers (I'm guessing it'll be closer to 50%).

Medical schools are increasingly depending on the EM specialty to help with teaching students at all levels of learning. For those of us invested in medical education, this is great news.

Reference
Wald D, Lin M, Manthey D, Rogers R, Zun L, Christopher T. (2010). Emergency Medicine in the Medical School Curriculum. Academic Emergency Medicine, 17 DOI: 10.1111/j.1553-2712.2010.00896.x
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Paucis Verbis card: Pediatric weight-based reference (5-34 kg)

The foundation in any pediatric resuscitation is the length-based estimation of the patient's lean body weight. Once determined, equipments and medications are sized and dosed, respectively, according to that weight. You can use electronic resources such as PEMSoft (Pediatric Emergency Medicine Software) or the more traditional paper-based Broselow tape.

If you have neither of these at your easy disposal, I thought I would create a multi-card reference which works best in electronic pdf form on your mobile device. (Remember, I'm also sharing my Paucis Verbis cards using Dropbox.) Even if you DO have other available references, it's still nice to have some redundant back-up sources just in case.

This data was collected by merging data from the Broselow tape and PEMSoft.

• I created 30 individual cards for patients weighing between 5 kg and 34 kg. 
• I didn't include whether endotracheal tubes should be cuffed or uncuffed. This is controversial currently. The traditional teaching is that patients younger than 8 years old should receive UNcuffed tubes.
• D10W glucose should be given in patients younger than 1 year old. D25W glucose should be given for patients 1-2 years old. D50W glucose can be given to patients 2 years and older.
• Please use these cards with caution. I've proof-read these cards multiple times, but there still may be some typos. Please let me know if you see any discrepancies.

Example card for 10 kg child:

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Disclosure- I am one of the editors for PEMSoft. I just returned from a KidsCareEverywhere's trip to Vietnam, where we taught over 200 pediatricians how to use the software to improve their resuscitation skills.

Practicing Judo in the ED: Secret to success

OK, you don't actually practice Judo in the Emergency Department, but the principles in Judo are interestingly relevant in approaching our work in the ED.

Thanks to Garr Reynolds of Presentation Zen fame for introducing me to the 7 rules of judo practice by the great Judo master Kyuzo Mifune. In his blog post, Garr specifically talks about how these rules are relevant in the realms of leadership and public speaking.

These rules in fact are extremely relevant when you are a senior EM resident or an EM attending. These 7 simple rules really are the heart of maintaining respect, calm, and efficiency in the ED.

1. Do not make light of an opponent.
Although it is easy to do, try to avoid speaking negatively about any consultants or ancillary services. It only breeds negatively and draws focus away from patient care. Give others the benefit of the doubt. Just because people may speak ill of the ED doesn't mean that you should reciprocate. I consider the ED team as having a higher set of professional standards.

2. Do not lose self-confidence.
You have been trained well in EM. This doesn't mean to be over-confident but rather just deliberate. Second-guessing yourself makes you inefficient. If you don't know an answer, just look it up, get help, or consult someone.

3. Maintain a good posture.
To me, this means positioning a patient appropriately so that you aren't straining to do a procedure. Is the bed too high or too low? Adjust accordingly.

4. Develop speed.
Practice not only your clinical skills but also your efficiency skills. Focus on developing your multitasking abilities and speed. Recently, I've been pre-writing a few Vicodin and Percocet prescriptions just before I start a shift. I then just write-in the patient's name and off they go with the prescription. A few minutes saved per patient adds up to significant time savings over the course of the shift.

5. Project power in all directions.
I interpret this as being professional at all times. As the senior EM resident or EM attending, you are the leader of the ED team. Whether you realize it or not, the tone of the shift is set by how you treat others. No interaction is unnoticed. Imagine that an invisible yet impressionable 1st year medical student is shadowing you at all times. Don't say or do anything you'd feel bad about in his/her presence.

6. Develop self-control.
Inevitably, sometimes patients or other providers can make you angry. They just are able to push your buttons. Be cognizant of when this happens and try your best not to reciprocate. This is harder said than done, but you lose serious credibility points all-around if you lose your temper. When I get flustered, I often have my default responses:

• "I'm just trying to do what I think is best for the patient."
• "I totally understand your perspective, but we are going to have to agree to disagree."
• "Could I talk to your attending?" (Usually ends heated discussions quickly when asked of a resident. I hate to pull the Attending Trump Card, but sometimes it's just necessary.)

7. Never stop training.

You will never learn everything there is to know in Emergency Medicine. That's the blessing and curse of the specialty. Keep reading. Keep learning. My goal is to always surprise a consultant with information that they don't think a typical emergency physician would know about their specialty.

Any other good rules for success in the ED?

Trick of the trade: Face mask ventilation in edentulous patients

Can you imagine trying to bag-valve-mask ventilating this patient without teeth?

Edentulous patients can cause BVM problems because air tends to leak out the sides of the mouth, because the cheeks don't contact the mask as well. You can do a jaw-thrust and/or place an oropharyngeal airway to help. What else can you do?

Trick of the trade:

"Lower lip" face mask repositioning

Reposition the mask more superiorly to improve the BVM seal. Normally the inferior edge of the mask sites between the lower lip and chin alveolar ridge. Move the mask a 2-3 cm more superiorly.

In an Anesthesiology publication, the authors prospectively studied 49 edentulous patients in the OR who had a BVM seal leak. The provider then repositioned the face mask more superiorly so that the inferior border of the mask sits just below the lower lip.

Median air leak volume:

• Traditional BVM technique: 400 cc leak
• Lower lip face-mask technique: 10 cc leak

It's important to use the 2-handed (instead of 1-handed) BVM technique to supplement the lower-lip face mask repositioning trick.

Thanks to Chris at Life In The Fast Lane for letting me know about this cool trick just published!

Reference
Racine SX, Solis A, Hamou NA, Letoumelin P, Hepner DL, Beloucif S, & Baillard C (2010). Face mask ventilation in edentulous patients: a comparison of mandibular groove and lower lip placement. Anesthesiology, 112 (5), 1190-3 PMID: 20395823

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Retinal detachment on ultrasound

I just wanted to revisit the Trick of using bedside ultrasonography to diagnose retinal detachments. I covered this also in a previous Tricks of the Trade post last year, but I just had to reiterate how easy it can be to detect it by ultrasound. Be sure to use plenty of ultrasound gel and use the linear tranducer.

The eye should normally appear as a circular hypoechoic structure. Above is a 7-second video I recently captured of a patient's eye in transverse view. The irregular, hyperechoeic stripe (bottom of screen) that you see floating in the anechoic posterior chamber is the patient's detached retina.

Oct 11-18: Disconnected from the internet

Apologies for the lapse in blog postings this upcoming week. Every once in a while, you just have to take a break and recharge. In the meantime, feel free to look through some of the older postings. There are over 300 postings, sorted by tags for your convenience (in right column).

Will be back on October 19, 2011.

Paucis Verbis card: C3-C7 spinal fractures

This is the second Paucis Verbis card on cervical spine fractures. Part 1 covered C1 and C2 fractures. This card covers the lower cervical spine fractures. These two tables are part of my chapter on "Spine and Spinal Cord Injury" in the textbook Emergency Medicine by Dr. Jim Adams (Northwestern EM Chair).

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Life of an Attending: Is this or will this be you?

(click to enlarge)

Thanks to one of our residents, Hangyul, I just recently learned about a hilarious comic strip series called Scutmonkey Comics in the blog The Underwear Drawer. It is side-splitting funny.

Check out this drawing depicting "Life of an Attending" from the perspective of the residents. I'm still chuckling about the Money Angels.

Trick of the trade: Discounted medications at pharmacies

Many times, patients who we deem as "noncompliant" with medications may actually be financially unable to afford medications that we prescribe them. Thanks to Amy Kinard, I just learned about this great new website where you can find pharmacies with amazing discounts for common medications.

http://www.genericmedlist.com

I went to Walmart and Target myself to see if this was indeed true, because frankly I couldn't believe the amazing deals. For example, you can get 20 tablets of ciprofloxacin (500 mg tabs) for only $4.

Download the list of eligible medications and the price list from:

• Target pharmacy 
• Walmart pharmacy

Even more cool is that fact that this same information can be found in a free iPhone app called Generics. Now you can refer patients to the most affordable pharmacy (see below).

EMS officially recognized as an EM subspecialty

EMS was officially recognized as an EM subspecialty by the American Board of Medical Specialities on September 23, 2010!

Residency programs have already implemented EMS Fellowship Training Programs to provide physicians with specialty training in prehospital care, medical direction, and research in the prehospital arena. The development of this new subspecialty was a collaborative effort between the National Association of EMS Physicians, the American College of Emergency Physicians, the Society of Academic Emergency Medicine, and the American Board of Emergency Medicine. The first certification exam is tentatively scheduled to be administered in 2013. Click here to see the announcement.

Prehospital care is one of the most challenging aspects of EM. Factors that make it challenging include the limited resources, possibly dangerous work environment, and the unpredictable patients.

Congratulations to all those involved with the past, present, and future of EMS!

Article review: Importance of first clinical clerkship

What was your first clinical clerkship rotation?

Oddly, I started my third year with a sub-internship rotation on the Burn/Plastics service as my first rotation. Not sure how that happened... I managed my own patients like a 4th year student, did lots of wound care, and even got to harvest a few skin grafts. It was trial by fire.

In a recent JAMA article, 3rd year medical students who started their clinical experiences in an Internal Medicine rotation overall did better on overall clerkship grades, when compared those who started their rotations on the Ob/Gyn, Psychiatry, or Family Medicine service.

These 3rd year medical students were spread across four distinct sites at the University of Illinois (Chicago, Peoria, Rockford, Urbana). An analysis of covariance was used to test for differences between groups. In this case, differences in the first clerkship rotation were compared with respect to:

• NBME shelf exam scores (score range 0-100)
• Student clinical performance ratings (score range 12-30)
• Overall 3rd year clerkship grades (score range 12-30)
• USMLE Step 2 exam scores

Results

Interestingly, students who began their 3rd year clerkships with Internal Medicine fared better on the NBME exams (p<0.001) and clerkship grades (p=0.02) during their entire 3rd year.

Specifically, they performed better than students who began their rotations with such specialties, such as Ob/Gyn, Psychiatry, and Family Medicine. Clinical performance ratings and USMLE Step 2 scores, however, were not associated with the the student's first clinical clerkship. 

It seems that the Internal Medicine rotation provides a crucial foundation in preparing for other clerkships. It is the best first clerkship for students just starting their clinical rotations.

Hmm, I wonder...
There has been a lot of talk about significantly reorganizing in the U.S. medical school curriculum. Much hype has focused on incorporating more clinical experiences as early as the 1st year of medical school. This study seems to suggest that students should all start with Internal Medicine as their first clinical experience. This, however, is logistically impossible because of limited space on the Internal Medicine teams.

This begs the question - Why DO students have to start medical school at the same time each year? Why can't medical schools enroll students on a rolling basis, such as on the 1st day of each month? This would allow a more equivalent clinical clerkship experience, because students can now follow the same sequence of clerkships. Everyone could start with Internal Medicine.

Reference
Kies SM, Roth V, & Rowland M (2010). Association of third-year medical students' first clerkship with overall clerkship performance and examination scores. JAMA : the journal of the American Medical Association, 304 (11), 1220-6 PMID: 20841536

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Paucis Verbis card: C1-C2 injuries

I'm starting to work on co-authoring the next edition of my chapter on "Spine and Spinal Cord Injury" within the textbook "Emergency Medicine" by Dr. Jim Adams (Northwestern EM Chair). There are some useful tables that I created that I thought you might find helpful. This is the first installment covering C1-C2 fractures. The next PV card will cover the lower cervical fractures.

I always forget which are stable and unstable. For instance, the above extension teardrop fracture looks innocuous but is an unstable fracture because the anterior longitudinal ligament is ruptured.

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

[MS Word] [PDF]

See other Paucis Verbis cards.