Computer simulation DIEM case goes live!

Welcome to the new age in medical education for EM!

I've been working on building these interactive, online simulation cases for CDEM for the past 2 years. Finally, the pilot case (a patient with chest pain) is finally out! EM medical students across the country are trying their hand at diagnosing and managing the patient. Preliminary data shows that the case is easy to navigate and students enjoy the ability to make decisions autonomously.

This is the first case in a series called "Digital Instruction in Emergency Medicine", or DIEM cases. These cases allow the user to navigate through a variety of patient complaints and presentations. Similar to high-fidelity simulation, these cases are dynamic, contain multimedia content, and provide a realistic approach to patient management; however in contrast, users can complete these cases anytime and anywhere. All you need is internet access and a computer with Flash capability.

The DIEM modules are especially unique in several ways:

• There is a timer built into the cases to enhance a sense of realism.
• Many parts of the physical exam are displayed for the user to interpret (rather than telling the user what was found).
• When ordering laboratory tests, each test must be justified.
• At the end of each case, the user is required to write up the Emergency Department chart. Documentation is a crucial skill, which medical students often do not get to practice enough in the age of Electronic Medical Records.
• Similar to true simulation exercises, case debriefing is just as important as participation in the case. There is a debriefing section for each DIEM module, which includes an area for self-reflection, a discussion of Critical Actions, and the "ideal" chart writeup.'

It really helps to watch the short instructional video above to help you navigate the case. You'll need about 45-60 minutes for the whole case (if you include the chart writeup and all of the debriefing info that follows the case).

Go to the DIEM case on Chest Pain

The DIEM cases will all live on the CDEM Curriculum site, which also houses the online EM textbook available for free. This was written by CDEM faculty members for the senior medical student level.

Pros and Cons of Social Media Use in Medicine

The American Medical Association (AMA) just released a policy on Social Media and Medical Professionalism. It focuses more on the negative aspects of social media, and much can be averted by just using common sense:

Physicians should weigh a number of considerations when maintaining a presence online:

• Physicians should be cognizant of standards of patient privacy and confidentiality that must be maintained in all environments, including online, and must refrain from posting identifiable patient information online.
• When using the Internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the Internet, content is likely there permanently. Thus, physicians should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate.
• If they interact with patients on the Internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just, as they would in any other context.
• To maintain appropriate professional boundaries physicians should consider separating personal and professional content online.
• When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.
• Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.

On the flip side, Greysen et al wrote a nice commentary piece in the Journal of General Internal Medicine about the positive applications of social media in Medicine.

• Provide insightful and respectful reflection narratives about clinical experiences that maintain patient anonymity.
• Promote quality improvement and patient safety guidelines
• Serve as a trustworthy source of medical information to balance less-reliable online resources

To quote the authors: "Much like a mirror, social media can reflect the best and worst aspects of the content placed before it for all to see."

Social media is here to stay. Let's figure out how to work with it rather than avoid it.

Reference
Greysen SR, Kind T, & Chretien KC (2010). Online professionalism and the mirror of social media. J Gen Int Med, 25 (11), 1227-9. 
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Happy Turkey Day!

Will need to think of some Tricks of the Trade for weight loss...

Signing off until Monday, November 29, 2010.

Trick of the Trade: Hemostasis of finger laceration

Lacerations of the finger can bleed quite profusely because of digital vascularity. This obscures the provider's ability to perform a careful exam and can make suturing quite difficult. Simple direct pressure over the laceration often controls the bleeding.

What if this doesn't work?

Trick of the Trade:

Glove tourniquet "ring"

Each finger receives blood supply from the radial and ulnar branches of the digital arteries. Hemostasis can be achieved by external compression of these branches. An elegant tourniquet can be made from a glove.

• Cut off the finger of a glove.
• Create a small hole at the distal tip of the finger glove.
• Put this finger glove on your own finger.
• Push and roll the finger glove proximally to create a tourniquet "ring".
• Remove the ring and apply on your patient's finger.

Tips:

• Avoid cutting too big of a hole at the finger glove tip in order to maximize tourniquet tension.


• If the tourniquet ring is still too loose, use the pinky finger part of the glove or select a smaller glove to start with.

Sharing Multiple URL Links at Once

More and more we're living on the net. For many academic physicians, the internet has become a work and a teaching tool. Whether you're sharing sites on a shift or forwarding links to the students, resident or colleague on a subsequent day, URL-shortening services can help you organize your links to favorite URLs, be more efficient, and. keep your email or blog text cleaner.

BIT-dot-LY or BITLY: This simple user interface allows you to enter a URL and get back a shortened version with one click. For example: I love showing my residents Michelle's Trick of the Trade for Irrigating Scalp Lacerations. I search for the blog post and enter the long URL into BITLY, and voi-la:

As you can see, http://academiclifeinem.blogspot.com/2010/01/trick-of-trade-irrigating-scalp.html became http://bit.ly/b50AeV, by entering a URL and a few clicks.

Hot off the press: Sharing URL links at once
This past week, BITLY and others began offering the option to share multiple long-URLs with bundled into one short-URL.

For example, I wanted to share with colleagues links to six of the simulation centers that are affiliated with Harvard Medical School, so instead of sharing all six long-URL's I simply created a bundle and shared. When it was all set and done,six long URLs got bundled elegantly into one: http://bit.ly/cxQWdH.

If you want more information, here is a review and directions from TechCrunch: http://tcrn.ch/dBKzuP.

FYI, you will have to get a free account in Bit.ly to do this. After logging in, you then just type in all the website URLs, separated by a {space}. As you type, each site URL gets shortened (see below). Then click "Bundle". Here is an example:

A single shortened URL link will be created. In this test case, this generated the code: http://bit.ly/bAUQKS. Click on it see the 3 combined links.

There are other sites that offer similar services such as BridgeURL and Clusters.

Happy surfing, sharing, blogging and posting (and Thanksgiving)!

Demian

Article review: Coaching in emergency medicine

After a chaotic shift, you and your learner sit down to complete the daily evaluation card. There are no significant issues with the learner. Is there anything else to write except 'great shift' or 'read more'?

Can we learn from excellent motivators such as sports coaches? This article by LeBlanc and Sherbino outlines coaching as a teaching technique in the ED.

How is coaching different from traditional teaching?

Coaching is dynamic - learner and teacher work towards a common, specific goal. The agenda is learner driven.

Coaches observe learners to provide feedback. They also follow up on behavior changes.

How can we use it in the chaotic ED?

Target coaching relationship to appropriate learners. Use short, discreet episodes for basis of teaching.

What are the elements of successful coaching?

1. Explore the learners' agenda. Set goals together.
2. Observe learners during short episodes.
3. Identify the gap in behavior.
4. Provide a learning plan. It should be specific to the learner's needs, and not a formal assessment.
5. Role model behavior and skills.
6. Ensure follow up to assess learner's progress.

Comments:

This article has pratical use for teaching in the ED. I have found myself wondering what to tell the capable learners as feedback. Using the coaching technique we will both know our common goals.

Observation, even though time-consuming, brings a wealth of information. I sometimes listen behind the curtain as I chart or review lab results!

What are your thoughts on coaching?

Reference
LeBlanc C, Sherbino J. Coaching in emergency medicine, CJEM 2010;12(6):520-524.
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Paucis Verbis: Identifying toxidromes by vital signs

A middle-age woman presents to the Emergency Department with altered mental status after having ingested a drug. Is it an opioid? Is it an antihistamine?

The key is to pay close attention to the vital signs. They are often the clue to the mystery. I found this great table from EM Clinics of North America by Dr. Timothy Erickson from 2007. I can't imagine how long it took for him to create all these mnemonics. I'll never remember these mnemonics, but they're fun to read nonetheless.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

New ACLS guidelines from the AHA, ERC, and ILCOR

Last month the AHA, ERC, and ILCOR released the 2010 Resuscitation Guidelines. They build on the 2005 and previous guidelines and continue the trend towards more, higher quality, uninterrupted CPR. The complete summary and recommendations are published in Circulation and are available for free.

Here is my summary for you!

CHANGE

• Trained rescuers should change BLS sequence from A-B-C to C-A-B
• Chest compression rate should be GREATER than 100 beats per minute
• Chest compression depth should be GREATER than 2 in./5cm.
• Untrained rescuers should perform Hands-Only CPR

DELETE

• "Look, listen, and feel" for breathing is no longer recommended
• Atropine is not routinely recommended for all PEA or Asystole cases
• Central venous catheters (deleted 2005, replaced by IV or IO)

ADD

• If available, continuous quantitative capnography is recommended throughout the peri-arrest period to assess physiologic change
• Adenosine is recommended for stable, regular, monomorphic wide complex tachycardia
• Post-cardiac arrest care including PCI and Therapeutic Hypothermia when indicated

Keep/Reinforce

Our colleagues from the blogosphere have published their audio and written summaries and opinions too:

EMCRIT.org summary and podcast: http://blog.emcrit.org/podcasts/acls-guidelines-2010/

Life in the Fast Lane: http://lifeinthefastlane.com/2010/10/resuscitation-guidelines-2010/

From my point of view, these guidelines include most of what we've been teaching students, residents, medics, nurses, and others in our simulation center with the addition of a few new pearls. It'll be helpful to show our colleagues these guidelines as we advocate for more CPR and less of other things in the prehospital setting and for more critical care, PCI and therapeutic hypothermia on the in-patient side. In the ED we will need to continue to improve our team work skills, communication with colleagues and families, and our ability to provide effective, efficient, and affordable care for all.

Demian Szyld, MD

Boston, MA

Trick of the Trade: Toe paronychia splinting

Ingrown toenails, or paronychias, are usually exquisitely painful and a bit gnarly when they present to you in the Emergency Department. Dr. Stella Yiu described toenail splinting techniques using steristrips or dental floss. The purpose of splinting is to prevent the toenail from growing back into the lateral nail fold.

This assumes a relatively mild-to-moderate case. Often simple elevation of the nail out of the lateral nail fold (under digital block anesthesia) is all that is needed to treat a paronychia. Pus is often released with this maneuver.

What do you do for more severe cases when you have to excise the lateral edge of the nail?
There's no toenail to slide the steristrip/ cotton/ dental floss material under.

Trick of the Trade: 
Angiocatheter in nail fold

I have heard of providers wedging a thin roll of cotton into the nail fold to prevent the nail from regrowing into an ingrown toenail again. I find, however, that the cotton absorbs too much moisture day in and day out, while sitting in the nail fold.

Alternatively, you can slide an 18-gauge angiocatheter (just the plastic part) into the potential space. The new nail should then grow over this plastic "splint". The above photo is of a patient's toe with a brewing ingrown toenail for over 1 month! Both edges needed to be trimmed down longitudinally. Way to go, med student ST. You know who you are.

The added benefit of the angiocatheter over the cotton is that if you needed to remove it for whatever reason, it's easier to remove as one piece than cotton.

I got this idea from the concept of a toenail "gutter splint" from this a review article from American Family Physician.

KidsCareEverywhere: 2010 Vietnam Video Documentary

KidsCareEverywhere is a non-profit group that I've been a part of for the past 3 years. I'm actually one of the Board Members and the Director of Research (since there's a large educational research component in our outreach efforts). The group delivers a clinical decision software (PEMSoft) to pediatricians in developing countries. This software essentially replaces their medical libraries and brings references and tools to the bedside.

I just returned from a recent trip to Vietnam. Got some amazing video footage and photos. It was tough to get things down to a 7 minute video.

It really is amazing what you can do with a little technology and a lot of free time:

• Three of us simultaneously edited the script on Google Docs from our respective homes.
• Adobe Flash is a software worth learning. It let me add in those nifty animations that can get converted into .mov format. These are then importable into iMovie. It can suck up all your time trying to get the animations just right, but a great visual goes a long way.
• I found a great Creative Commons website with royalty-free music by Kevin McLeod. If you need some great background soundtracks, check it out here.

Article review: Pitfalls in writing test questions

Which is the best answer?

• A. Yes
• B. No
• C. Maybe
• D. 2 of the 3 above
• E. None of the above

Wait, what?! 

What a terribly written test question! 

Have you encountered similarly poor questions on exams? It turns out that writing multiple-choice test questions is actually pretty difficult. There are some basic rules to follow and pitfalls to avoid.

In an article, the authors (hey, I know most of them! Wait, why wasn't I invited?!) talks about the lack of a National Board Medical Exam in Emergency Medicine. Such "shelf exams" exist in other specialties but in EM. Frankly, it has to do with how expensive it is for medical schools and clerkships to purchase these tests. Within EM, 59% of clerkships are using an end-of-clerkship exam, most of which are designed by the local institution.

The authors also provide an excellent review on the art of writing multiple-choice test questions.

So what are the basics in writing a good multiple-choice test question?

There are 2 parts to each test item:

1. The stem: The question itself
2. The answer choices: Keyed response (correct answer) vs Foils/Distractors (wrong answers)

The Stem

• The test question should be clear and answerable without looking at the possible choices.
• The test question should have only one undisputable answer.
• Avoid being too wordy. State the question concisely.
• Avoid "negative" questions (eg. Which of the following is NOT a cause for...)

The Answer Choices

• There are smart test-takers out there. For instance, choices which have the word "always" or "never" are usually foils and thus incorrect answers. Grammatically incorrect choices are usually wrong. When choosing between 2 answers, the really long one is often the right choice, because the test-writer wants clarify and ensure that the answer is correct. Be aware of these when writing the keyed response and foils.
• When listing the choices, put the responses in logical order (alphabetical or numerical).

The authors also discuss the importance of determine test reliability and content validity. Are the students performing poorly because you just suck at writing test questions? Perhaps a better solution than having all the clerkships working in isolated silos is to have a single validated exam.

Thus, the authors conclude the need for a standardized, national EM final exam, now that a formal EM curriculum has been created by CDEM this past year.

Reference
Senecal E, Askew K, Gorney B, Beeson M, Manthey D. Anatomy of a Clerkship Test. Acad Emerg Med, 2010, 17: S31-37. DOI: 10.1111/j.1553-2712.2010.00880.x
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Paucis Verbis: Illustration to describe thrombolytic risk

How do you describe the risks and benefits of thrombolytics to your patients and their families in the setting of a thrombotic stroke? Thanks to Dr. Mike Klevens, here is an illustrative graphic to help you explain. Just an example of a well thought-out graphic being far superior to words. This graphic is from the UCLA Stroke Center.

I'm going to add to the Paucis Verbis card on "Contraindications to Thrombolytics".

UPDATE 11/16/10: 
Use this thrombolytics graphic with caution. Read the comments below.

ACGME Duty Hour and Supervision Standards

Hot off the press!

The Accreditation Council for Graduate Medical Education (ACGME) recently released the final version of guidelines relating to duty hours and supervision standards. These changes will affect 110,000 residents within the ACGME's 8,800 accredited residency programs in 133 specialties and subspecialties. Providing an exceptional graduate medical education as well as ensuring patient safety were highlighted goals.
Some of the prior standards:

1. A duty hour limit of 80 hours per week.
2. Requirements in the levels of supervision for first-year residents.
3. A work day of 16 hours or less for first-year residents.

A sample of the new changes:

1. Establishing graduated requirements for minimum time off between scheduled duty periods. For instance: "Duty periods of PGY-1 residents must not exceed 16 hours in duration. Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested."
2. Expanding program and institutional requirements regarding handovers of patient care.
3. Setting more specific requirements for alertness management and fatigue mitigation strategies designed to ensure both continuity of patient care and resident safety.

These new standards will go into effect in July 2011. More information can be found here.

What are your thoughts on duty hours

and supervision standards???

For similiar blog discussions of duty-hours, based on the Institute of Medicine 2008 recommendations and their relevance to EM.

• Hidden Costs of Reducing Duty Hours
• EM Consensus Response to Duty Hour Recommendations

Trick of the Trade: Ultrasound-guided supraclavicular central line

Emergency physicians are procedural experts in central venous access. The subclavian vein is the best site for such access, because it has been shown to have the lowest rate of iatrogenic infections and deep venous clots.

Bedside ultrasonography has really revolutionized how we obtain vascular access over the past 10 years. Identifying the subclavian vein using ultrasonography, however, is still technically challenging. The vein is located just posterior to the clavicle, which often gets in the way of the linear transducer.

Trick of the trade:
Ultrasound-guided supraclavicular central line

Did you know that there are two approaches to access the subclavian vein -- infraclavicular and supraclavicular? The traditional approach is the infraclavicular approach, however, more studies are showing that the supraclavicular approach is just as safe and as procedurally easy as the infraclavicular approach.

The subclavian vein courses posterior to the clavicle but reaches its most superior point just lateral to the clavicular belly of the sternocleidomastoid muscle. In the above photo, the needles are pointing to insertion site for both the supra- and infraclavicular approaches.

Use the ultrasound to guide your supraclavicular line placement.

Instead of using a flat linear transducer, use the endocavitary transducer, which emits a similar high frequency signal. Its footprint is much smaller and more curved, allowing you to better visualize the subclavian vein. Position the transducer so that you get a long axis view of the vein. Often you can also see IJ vein in view, merging with the subclavian vein.

I unfortunately don't have an ultrasound image of this. If you have one, could you send and I'll post it? I'd be happy to credit you. 

There is a good, copyrighted image in the article by Mallin et al. This survey study showed that 15 residents felt more comfortable with identifying the subclavian vein using this technique after a brief training period.

Reference
Mallin M, Louis H, Madsen T. A novel technique for ultrasound-guided supraclavicular subclavian cannulation. Amer J Emerg Med, 2000, 28 (8), 966-9. 
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Teaching Evidence-Based Medicine on the go

You just examined a patient with COPD exacerbation with a trainee.

Your trainee asks, "What is the evidence behind non-invasive positive pressure ventilation (NIPPV)?" You remember a few papers about it, but not the specifics about the studies. Are there quick sites to search on the fly without looking up Google or Wikipedia?

Introducing: 

EBM on the go

http://ebmonthego.com/

This website contains a list of high-quality sites with Evidence Based Medicine (EBM) literature. Some sites have commentary, and some have quick sections that can be skimmed. It is built by Dr. J Thull-Freedman, a pediatric emergency physician at Hospital For Sick Children in Toronto, Ontario.

Here is a search via DARE (Database of Abstracts of Review of Effects):

This is a great platform to search the most updated information quickly. I am definitely going to use it at work!

Article review: The "Good" Dean's Letter

'Tis the season. 

Residency interview season, that is.

• Faculty are trying to sort out the piles of ERAS applications, trying not to zone-out while reading their 50th personal statement over the past 4 hours. Does it seem that medical students are getting more and more amazing every year?! I'm glad I got in when I did.
• Student forums are abuzz with residency program and interview etiquette questions.
• Students are second-guessing themselves about why they haven't heard from their first-choice program.
• Students are starting think about whether they still fit in their business suit from 4 years ago, when they interviewed to get into medical school.

I came upon this article in Academic Medicine, written by Emergency Medicine faculty like my friend Dr. Annie Sadosty (Mayo Clinic). The Dean's Letter, also known as Medical Student Performance Evaluation, is a summary evaluation of the graduating medical student. It is a key document that application-readers look at.

The authors conducted a retrospective, multicenter, chart review study at 3 residency programs. Two data abstractors independently looked at the 2007-08 Dean's Letters of all the applicants in the programs. They searched for the term "good" in the summary statement and appendices of each Dean's Letter, to find whether it correlated with the student's ranking.

Result
The adjective "good" was used in 34 of 122 (28%) institutions to classify the students into performance tiers. Of these 34 institutions, 25 (74%) used "good' to describe a student in the bottom quartile of the class (0%-25%). All 34 institutions used "good" to describe students performing in the bottom half of the class.

Conclusion
The authors concluded what some of us have learned through personal experience of reading hundreds of files. On the Dean's Letter, GOOD is a code word for BAD usually. This study illustrates the need for a more standardized tool or template for reporting student performance. Variability makes it really difficult for residency program directors to compare students from different medical schools.

The authors propose that that all medical schools should adopt a standardized approach to writing the summative portion of the Dean's Letter.

Tip
In the meantime, if you are writing letters of recommendations for anyone, try to avoid the term "good" for now. You never know if letter readers automatically interpret this as having a negative connotation.

Reference
Kiefer CS, Colletti JE, Bellolio MF, Hess EP, Woolridge DP, Thomas KB, Sadosty AT. The "good" dean's letter. Academic Medicine. 2005, 85 (11), 1705-8. PMID: 20881821
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Paucis Verbis: Sgarbossa's Criteria with LBBB

It is difficult to determine if a patient with a left bundle branch block (LBBB) has an acute myocardial infarction (AMI) because ST segments are "appropriately discordant" with the terminal portion of the QRS. That means if the QRS complex is negative (or downgoing), the ST segment normally will be positive (or elevated). Similarly if the QRS complex is positive (or upgoing), the ST segment will be negative (or depressed).

In 1996, Sgarbossa et al looked through the GUSTO-1 trial patients with LBBB and AMI. They derived 3 criteria which may help diagnose the "hidden" AMI. The criteria are:

1. ST elevation ≥ 1 mm concordant with QRS complex (most predictive of AMI of the 3 criteria)
2. ST depression ≥ 1 mm in lead V1, V2, or V3
3. ST elevation ≥ 5 mm where discordant with QRS complex

Criteria 1            Criteria 3              Criteria 2

Thanks to Tom Bouthillet at ems12lead.com for the useful illustration above.

Use these criteria with caution though. None of these criteria are perfect. They are to help you risk-stratify. For instance, criteria #3 (ST elevation ≥ 5 mm) can exist in asymptomatic patients with LBBB because of concurrent left ventricular hypertrophy and high voltages.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Residency interview season: Pitfalls

I often get asked by my advisees: "In my residency interview, what should I talk about or do to make myself more competitive?"

To help you demystify the interview process, I wanted to share with you some insights. Overall, the interview day itself helps the program put a person and personality with your online ERAS application. Similarly, you quickly get a sense of the program's personality. In EM, the residency interview day is generally pretty laid back. Not too many crazy questions. Programs just want to get to know you. Both you and the program should be asking each other-- Is this a good fit?

In terms of making your application more competitive, I personally find that interviews don't actually help your cause. Your performance on interview day can, however, HURT your application. Can it hurt so much that you get dropped down several slots on the program's Rank List? Yup. Can it hurt so much that you get dropped off the Rank List entirely? You betcha.

Here are some pitfalls to avoid on your interview day:

1. Do NOT be late to your interview day. Map it out. Factor in traffic and weather. Get there early to be sure. Trust me, the program notices.
2. Do NOT get drunk or do anything that you'd regret at the pre-interview social event. Don't let the casual atmosphere trick you. You are still being observed. 
3. Do NOT be a gunner. Unsolicited remarks about how great you are isn't appreciated by anyone. The program already knows of your accomplishments. This is a time to show off your social skills and ability to fit into a team.
4. Do NOT be clueless about the residency program. Spend a few minutes at least looking at the program's website to familiarize yourself with the program.
5. Do NOT lie in your interviews or on your application. Students have been found to list themselves as participants of projects and authors of publications/abstracts which don't actually exist. This is a major professionalism issue, which no program wants a part of.
6. Do NOT leave your Facebook open to the public. Professionalism and social media is becoming an increasingly hot topic in Medicine. Why place yourself in the middle of controversy? Close your account to friends and family only. I've heard of a few programs scouring through their applicants' Facebook accounts.
7. Do NOT be texting or checking email constantly during the interview day. An occasional check is fine. Programs notice when you are constantly on your iPhone or Blackberry and aren't engaged in the day. This is really your only time to figure out if the program is a fit for you over the next 3-4 years.

Does anyone else have additional pitfalls or pearls to add?

Trick of the Trade: Legg Maneuever for shoulder dislocation

There are many ways to relocate a shoulder dislocation. Most of these ways require procedural sedation. What if the risks of procedural sedation outweigh the risks? What alternative maneuver can you try, which only requires parenteral pain medications +/- an intra-articular lidocaine?

Trick of the trade:
Legg Maneuver

Thanks for this guest contribution by Dr. Peter Lunny (EM-3) and Dr. Kevin Brody from Henry Ford Macomb (Michigan).  This maneuver will also be featured in a future ACEP News "Tricks of the Trade" column.

An osteopathic physician, Dr. William J. Legg, in family practice invented the Legg Maneuver in the 1980’s. This technique incorporates motions, which serve to neutralize muscle groups, which typically resist shoulder relocation. Usually this procedure can be done without using procedural sedation.

Two practitioners are required to apply the Legg technique. The assistant stabilizes the unaffected shoulder while the physician stands at the side of the injured shoulder.

• Position the patient seated upright on a stretcher to minimize movement of the upper body.
• Have an assistant stabilize the patient's uninjured shoulder by applying slight downward and backward pressure to keep it against the stretcher. Stabilization must be maintained throughout the procedure. 
• Abduct the injured arm to an angle 90° to the body. This minimizes the tension from the supraspinatus and deltoid muscles.

• Rotate the arm externally, such that the patient's palm is facing forward. This minimizes the tension from the infraspinatus and teres minor muscles.
• Flex the patient's elbow to a 90° angle. This minimizes the tension from the coracobrachialis and biceps muscles.

• Moves the injured extremity behind a coronal plane passing through the patient's occiput.

• Adduct the arm, fully flexing the elbow.

• Internally rotate the arm across the chest.

Reference
Dyck DD Jr, Porter NW, Dunbar BD. Legg reduction maneuver for patients with anterior shoulder dislocation. J Am Osteopath Assoc. 2008 Oct;108(10):571-3. PMID: 18948640

New kid on the block: Univ of Washington EM residency

How awesome would it be if there were EM residency programs at the University of Washington and UCSF-SF General Hospital?!

This has been the question for decades. In 2006, I had the pleasure of seeing the UCSF-SFGH program become a reality. And now it's the University of Washington's turn. It is close to becoming a reality. It is really one of the last powerhouse institutions which does not have an EM residency program.

The Univ of Washington EM residency's Program Director is helmed by my superstar friend, Dr. Fiona Gallahue, and will be a 4-year program. The ACGME (accrediting organization) has already site-visited the program. Short of an unforeseen snafu, I can't imagine that it won't be approved for a start year of 2011-12. The program will find out the official answer on February 14, 2011.

I can attest that there's nothing like that first-year's class in a new residency program. You have to be comfortable being a trail-blazer, leader, guinea pig, and all-around go-getter.

So in the likely event that they are approved by the ACGME, the residency program is accepting applications outside of the ERAS system. If you are a senior medical student applying into EM, you might consider sending your application to them. They're a worth a look-see.

Here are the instructions on how to apply:

While we are not listed on and are not accepting applications via ERAS, the process is quite simple.  Applications will be submitted directly to the University of Washington Emergency Medicine residency office and will include the same elements as those submitted through ERAS.  Our interview season is mid-November through mid-January.  For any questions regarding the residency or the application process, please contact either Fiona Gallahue at fiogal@uw.edu, or call or e-mail Samantha Groom (Program Manager) at 206-744-2556 or scgroom@uw.edu.  

Further information about our residency is also available on our website: http://depts.washington.edu/doemuw/.    

Article review: Inaccuracy in the SLOR

Residency interview season is quickly approaching! 

Unique to the field of EM, letters of recommendations from EM faculty are written on a standardized form. The Standardized Letter of Recommendation (SLOR), downloadable from the CORD website, documents information about the student's performance in the EM clerkship, qualifications, and global assessment. At the end, the letter writer can provide free-text written comments.

In the Global Assessment section, one question is:
How highly would you estimate the candidate will reside on your match list?

The tiered choices include:

• "Very Competitive": If you anticipate the student being in the 2X position of your program's Rank Order List, where X is the number of PGY-1 positions available in your program 
• "Competitive": If you anticipate the student being 2X-4X 
• "Possible match": If you anticipate the student being 4X-6X 
• "Unlikely to match": If you anticipate the student being greater than 6X

At a previous CORD Academic Assembly, I was lamenting with a few of my EM friends like Dr. Leslie Oyama (UCSD) about how inconsistently letter writers follow these guidelines. Overall, we felt that faculty inflated the student's Global Assessment Score (GAS) tier.

So we set out to figure how whether GAS tiers were truly correlated with the Rank Order List. Our results were just published in the CORD/CDEM educational supplement of the Academic Emergency Medicine journal.

Methodology
Our study was a multicenter retrospective study of 5 residency programs during the 2008-09 residency application cycle. For each SLOR written by the program's faculty, the GAS tier was recorded and compared to that student's actual Rank Order List position.

Results
Of the 102 SLORs, only 26% (n=27) of the SLORs documented a GAS tier that accurately predicted the student's actual position on the Rank Order List. The student's position was overestimated in 66% (n=67) of the SLORs and, interestingly, underestimated in 8% (n=8) of the SLORs.

Why the inaccuracies?
Our author group felt that there were 3 primary reasons for these inaccuracies between the GAS tier and Rank Order List

• It's not obvious on the SLOR form that Global Assessment Scores are supposed to be based on the student's anticipated Rank Order List position. Novice letter writers may not know of the grading scheme. It's only described on the CORD website.
• Determination of a student's position on the Rank Order List is a multifactorial process. Factors include the EM clerkship grades, USMLE scores, other letters of recommendations, preclinical and clinical grades, and extracurricular activities. One of the most important factors is the Dean's Letter (Medical Student Performance Evaluation). Most letter writers don't have access to this document when writing the SLOR. The Dean's Letter would have comments about disciplinary actions, failed exams, and other "red flag" instances.
• Faculty want to advocate for their student in the residency match process. They may feel pressured to inflate the GAS tier. For instance, while the student may be in the 6X+ range on the Rank Order List, some faculty may feel that labeling them in the lowest category of "Unlikely to Match" would unfairly penalize the application of a solid applicant.

What now?
Personally, I think that the Global Assessment Score of the SLOR document is unnecessary. Because of its inaccuracies, it's hard for the letter reader to put much weight in it.

Additionally, there's already another assessment tool in the SLOR which essentially gives the letter reader a sense of the student's overall competitiveness (see below). It's especially helpful because you can determine whether the letter writer is a "grade-inflater", because the letter writer has to break down how many letters s/he has written last year within the categories of Outstanding, Excellent, Very Good, and Good. Grade-inflaters, for instance, may have a track record where all of their students fall into the Outstanding category.

References
Oyama L, Kwon M, Fernandez J, Fernández-Frackelton M, Campagne D, Castillo E, Lin M. Inaccuracy of the Global Assessment Score in the Emergency Medicine Standard Letter of Recommendation Acad Emerg Med, 2010; 17:S38-S41. DOI: 10.1111/j.1553-2712.2010.00882.x
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