Article Review: Morbidity and Mortality Conferences in EM

Residency training programs are required to have Morbidity and Mortality (M&M) Conferences, as mandated by the Accreditation Council of Graduate Medical Education (ACGME). These conferences were originally designed to look at medical errors and unforeseen complications in patient care.

Traditionally, Surgery programs focus on medical error and complications in their conferences. In contrast, Internal Medicine programs tend to focus more on cases because of their intrinsic learning value. Error is less the focus in their conferences. What are the practices of EM residency programs?

This paper reviews a descriptive survey study of M&M Conferences in U.S. EM residency programs.  The response rate was 72% (89 of 128) for the 29-question survey. If you include all the active EM programs out there (n=135), the response rate was 66%.

Results

• Bottom Line: M&M conferences are varied in format, content, and timing.
• Some M&M conferences are alternatively called "Quality Improvement Conference" or "Interesting Case Conference"
• 67% of programs hold M&M monthly, and 15% hold them weekly.
• 33% of M&Ms are attended by nurses and EMS personnel.
• Some programs focus more on pediatrics, others more on trauma, and others primarily on cases where death or error was the outcome.
• 79% of programs have a protocol in place when a medical error is identified.

The authors note that the M&M Conferences are perfect venues to address key ACGME Core Competencies into resident education (especially Practice-Based Learning and Improvement and Systems Based Practice).

The next step is to determine the best models for M&M Conferences and to try to standardize them across all programs.

(click to open a larger image)

For our program at UCSF-SFGH, discussion and suggestions for improvement are framed within the Vanderbilt Healthcare Matrix for improvement health care practices. The matrix includes a 6x6 table with the Institute of Medicine mandates on one axis and the ACGME competencies on the other. Download the Matrix from the Institute for Healthcare Improvement (IHI) website.

Reference
Seigel T, McGillicuddy D, Barkin A, Rosen C. Morbidity and Mortality Conference in Emergency Medicine The Journal of Emergency Medicine. 2010, 38(4), 507-11. DOI: 10.1016/j.jemermed.2008.09.018
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Paucis Verbis card: The Shoulder Exam

How many times have you had to look up the shoulder exam maneuvers for patients with acute shoulder pain? I don't know why I just can't seem to remember these.

This Paucis Verbis card is a quick reference card to remind you of the most common techniques. Thanks to Jenny for the idea.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Video: Learners need to move from Knowledgeable to Knowledge-Able

Dr. Michael Wesch is an Associate Professor of Cultural Anthropology at Kansas State University whose niche in studying how media affects society and culture.

In this video, he illustrates how social media and the internet make traditional, one-way, passive learning in classrooms outdated. We have greater connectivity now. Traditional classrooms and institutions are being replaced by more dynamic, global learning environments, where everyone has a voice. We now have classrooms without walls.

He uses examples in environmental advocacy, music, disaster management in Haiti, and even his own classroom.

Trick of the Trade: NEJM This Week app

How do you keep up with the medical literature?

• You can carry around articles in your lab coat to read when you have a free moment.
• You can read pdf articles on your laptop at home.
• You can listen to podcasts reviewing literature.

Trick of the Trade: 

NEJM This Week app

About six months ago, the New England Journal of Medicine released a mobile app for the iOS platform (iPhone, iPod Touch). Free-access articles from the past 7 days are available to read. There are also select articles from the Images and Videos series. Audio podcasts are also available which review recent articles.

This a pretty cool app, especially because it's free. It would be great if more journals followed this innovative initiative.

Video: Where do good ideas come from?

Where do good ideas come from?

• They often are a collective of good hunches which develop over time.
• Ideas need time to incubate.
• There needs to be a place or venue to share hunches (eg. the Internet and social media platforms)
• Connectivity drives innovation and creativity.

This short 4-minute video by Steven Johnson is an example of a creative way of delivering your message. All you need are 2 markers, good handwriting, ... and oh, an amazing ability to sketch in super-human speed.

Article Review: Online curriculum for non-EM residents in the ED

In many academic Emergency Departments, there are "off-service" or non-EM residents rotating in the department. They are sometimes invited to the EM residency conference series for the month. Often times though, they have too many departmental didactic events and obligations of their own that they don't have time to attend formal EM didactics.

This is the perfect opportunity for an online didactic curriculum, which can be viewed at the residents' own time. The faculty at Northwestern designed such a curriculum, called the Northwestern University Rotating Resident Curriculum (NURRC). The curriculum consists of 6 voiceover lectures:

• ENT and Ophthalmology
• Environmental
• Obstetrics and Gynecology
• Orthopedics
• Toxicology
• Trauma and Wound Care

Methodology

The NURRC team conducted a 9-month, prospective, randomized study of 54 rotating residents (internal medicine and surgical subspecialties). All residents took one of two 42-question tests (A or B) as a pretest. The residents were then randomized into the control (no formal didactics) or experimental group (NURRC access). 

At the 2-week mark, both groups took the other test as a post-test (A or B). NURRC access was then made available to the control group as well. At the end of the 4 weeks, both groups completed an anonymous satisfaction survey. All residents who completed study participation received a $10 gift card to a local cafe.

Results

• 54 of 58 residents completed the study (92%)
• There was no difference in pretest scores between groups (52.6% controls, 50.8% NURRC group)
• The post-pre test score difference was 1.6% (control) and 17.3% (NURRC group)
• 43 of the 54 resident completed the survey (79.6% response rate)
• All lectures received at least a 80% approval rating.

My Thoughts

Although this study had a relatively small sample size (n=54), there were things that the investigators did right:

• Although 5 of the NURRC group admitted to not viewing the online modules, they were kept in the study group based on the intention-to-treat model.
• There was a great participation rate (92%) and survey response rate (79.6%). I'm guessing the gift card made a big difference.
• A linear regression analysis was performed to show that test version (A vs B) and resident specialty did not impact the study results.

Reference
Branzetti JB, Aldeen AZ, Foster AW, Courtney MD. A Novel Online Didactic Curriculum Helps Improve Knowledge Acquisition Among Non-Emergency Medicine Rotating Residents. Acad Emerg Med. 2010, 18:53–59. PMID: 21175925
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Paucis Verbis card: Generalized Convulsive Status Epilepticus

How do you manage patients who present in status epilepticus, knowing that "time is CNS function"? The longer patients remain seizing, the greater their morbidity and mortality.

Did you know that one study showed that 48% of their patients who presented in generalized convulsive status epilepticus (GCSE) had subtle persistent GCSE on EEG, despite no clinical evidence of overt seizure activity? That's scary.

Do you send off a serum tricyclic toxicology screen for all your patients with GCSE? Because of the prevalence of TCA overdoses locally, our Neurology consultants definitely order it. We are picking up a surprising number of positive tricyclic tox screens.

Summary of medications used to manage GCSE:

(from figure 1 of article) 

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Shearer P, Riviello J. Generalized convulsive status epilepticus in adults and children: treatment guidelines and protocols. Emerg Med Clin N Amer. 2011, 29(1), 51-64. PMID: 21109102
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VIPER video: How to give effective feedback

A few years ago, Dr. Esther Choo and I created a fun 15-minute instructional video on called Giving Effective Feedback: Beyond "Great Job". We had a blast recording sample feedback scenarios with our faculty and medical students. For every 1 minute of published footage, there were at least 9 minutes of bloopers and laughter! We definitely should keep our day job.

Giving effective feedback is something that faculty aren't necessarily taught before starting their position. It's just assumed that we know how to do it, and how to do it well.

I'm adding this video to the VIPER videos page as well.

Tricks of the Trade: Nursemaid elbow reduction

We've all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child's arm is either broken or dislocated. We all recognize this as radial head subluxation or "nursemaid's elbow" and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? Does the parent scream and threaten to sue? What if nothing happens?


Trick of the Trade: Hyperpronation technique
A 2009 paper by Bek et al. describes a method of pronation instead of supination. The proposed maneuver involves one hand holding the elbow at 90 degrees of flexion and the other hand holding the wrist. The wrist is then hyperpronated to complete the reduction.

Sixty-six patients were randomized to either a traditional reduction or the hyperpronation maneuver. If the initial attempt failed, a second attempt was performed. If the second attempt failed, then the alternate method was performed. Bottom line...hyperpronation was 94% successful on the first attempt compared to supination-flexion at 69%. Three patients failed supination-flexion (first and second attempt) but were successfully reduced with hyperpronation on the first attempt. Hyperpronation was also subjectively rated as significantly easier then supination-flexion by the practitioner.

I've been using hyperpronation for the past several years and love it. The maneuver appears less traumatic on the child (and parent).

Has anyone else tried it? I'd love to hear your experiences!

Reference
Bek D et al. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial European Journal of Emergency Medicine. 2009, 16(3), 135-8. DOI: 10.1097/MEJ.0b013e32831d796a

Academics vs community practice

If you don't already know about the amazing site ERCast by Dr. Rob Orman (Portland, Oregon), you need to take a look. The most updated podcast is on how one decides between an academics versus community practice setting. Guest speakers include Dr. Rob Rogers (Univ of Maryland, EM-RAP Educator's Edition podcasts) and Dr. Scott Weingart (Elmhurst Hospital/Mount Sinai, EMCrit podcasts).

Rob Orman's great website of podcasts:

http://www.ercast.org/

Click on the small "Pod" icon

Academic physician
Rob R. and Scott talk about how academic faculty positions have evolved from a very teaching-centric opportunity towards those where faculty need to "do it all" -- teach, focus on patient through-put, see some patients primarily, do administrative work, and conduct research. Furthermore, you need to deal with a constantly rotating, army of consultants and off-service residents in the ED who may pose as challenging personalities.

In academics, there are traditionally 2 types of tracks - Clinical-Educator and Clinical-Research. Keep a lookout for a new trend where departments are hiring physicians for a pure Clinical track. This track allows physicians who love to do bedside teach but don't really want to participate in other didactic or research projects. Those in the pure clinical track may be a new track in the future.

What academicians find surprising is just how hard it is to balance all of the job responsibilities which may or may not receive protected time from shifts. This includes:

• Working shifts
• Attending administrative committee meetings
• Troubleshooting departmental issues
• Teaching at residency conferences
• Giving national lectures
• Traveling to national meetings
• Trying to get published so that you can get promoted, AND -- oh, by the way -- 
• Balancing life

One thing mentioned that I was also surprised by is that there are different criteria for promotions in academia depending on where you work! Some hard-core institutions require rigorous, original research publications to get promoted. Others require more loosely-defined academic work, which may include lectures or review publications.

Community physician
Rob O. talks about how a community emergency physician is a stressful experience because all decision points need to filter through the emergency physician -- doing procedures, handling administrative hurdles, and seeing ALL the patients primarily. There are no residents to help see patients primarily or help with procedures. It's all YOU. On the flip side, it's all you when it comes to procedures. For those who enjoy doing procedures (and not giving them up to the residents), the community practice setting is terrific.

Bottom line
Both types of positions have unique stressors. For a graduating resident, the question will be deciding what set of pros and cons best fit your interests and lifestyle.

Listen to this great 60-minute panel discussion for more nuggets of wisdom.

Article review: Academic professional bankruptcy

In academia, faculty are expected to do it all-- clinical care, bedside teaching, formal didactics, scholarly work, and administrative projects. Asking for protected time, or release time from clinical work, from your department chair is often a difficult negotiation process, especially for junior faculty.

Fresh out of residency and fellowship training, junior faculty are just excited to get started as an academic faculty member. A downpour of exciting opportunities descends upon you, and you just can't say no to them! A year later passes, and you realize that you are overwhelmed.

The authors of this paper describe the concept of declaring "professional bankruptcy"in academics. In our struggling financial times, major companies can declare bankruptcy to allow time for rehabilitation and restructuring. The authors argue: Why can't extremely over-extended academicians do the same?

As a junior faculty, if you feel that your current load of clinical work, responsibilities, and duties is unsustainable, you might consider declaring "professional bankruptcy". This doesn't mean that you quit your job, but rather hit the reset button. The authors suggest a 10-step approach to negotiating this reset process.

1. Seek professional guidance. In academia, this means finding mentors, who can help you set realistic professional and personal goals.
2. List your assets. Identify stakeholders -- people and projects who have a stake in your career and obligations.
3. Market your assets. Find what aspects of work that you find most satisfying. Ideally, these are directly in line with what your institution and department value.
4. Offer creditors a partial return on investment. Instead of writing 5 textbook chapters, attending weekly Quality Improvement administrative meetings, and teaching monthly at residency conference, you finish 1 complete textbook chapter, attending the QI meeting every OTHER week, and teach less frequently at residency conference.
5. Sell off unprofitable divisions. This might mean doing a realistic assessment of what you value most in your academic career. Those not making the cut should get dropped, if possible. This means jettisoning the random administrative committee that you are on or the authorship of yet another textbook chapter.
6. Consider stimulus funds. This means "double-dipping" your efforts so that you magically create more virtual time for your projects. For instance, creating a new clerkship curriculum may also be the subject of a publishable manuscript. Each hour of time now has double the impact.
7. Outsourcing. Find enthusiastic residents or medical students to mentor and collaborate with on projects.
8. Rebranding. Find out what your core niche will be, and try to align this with your department's strategic plan. 
9. Consider a new job. If your niche and interests are completely out of alignment with your department's goals, you might need to find a new position. You may be a circle piece trying to fit in a star-shaped puzzle. Face it - you will never fit. 
10. Take steps to frequently reassess. As you are getting out of professional bankruptcy, periodically reassess your progress with your mentors to avoid bankruptcy again.

Reference

Thornburg LL, Glantz JC, Caprio TV, Gillespie SM. Professional Bankruptcy for the Academic Physician. J Grad Med Educ. Sept 2010, 2(3), 485-7.

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Paucis Verbis card: Workup for first-time seizure

How do you workup adult patientsm who present with a new-onset seizure and now neurologically back to normal?

There unfortunately is very little recent literature about the best workup approach. In 1994, the American College of Emergency Physicians (ACEP) published a Clinical Policy based on expert consensus. The EM Clinics of North America series also just published a review on the topic. The bottom-line is that there are two types of workup approaches.

For the uncomplicated cases (age less than 40 years, afebrile, no comorbidities, no neurologic deficits), the workup is fairly minimal, which includes:

• Glucose and electrolytes
• Urine pregnancy test, if appropriate
• +/- Urine toxicology screen
• Head CT (noncontrast)

Otherwise, the more complex cases require a more extensive workup, which may include a lumbar puncture in the setting of a fever, severe headache, immunocompromised status, or persistent altered mental status.

Pearl: Be sure you obtain a head CT for patients who you think are presenting with a simple new-onset, alcohol-withdrawal seizure. One study showed that 6.2% of these patients actually have a significant lesion on CT (eg. bleed, mass).

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference

ACEP Clinical Policies Committee, Clinical Policies Subcommittee on Seizures. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Annals of EM. 2004, 43(5), 605-25. PMID: 15111920

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Jagoda A, Gupta K. The emergency department evaluation of the adult patient who presents with a first-time seizure. EM Clinics of North America. 2011, 29(1), 41-9. PMID: 21109101

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Need your help! Favorite medical apps

So, I volunteered to give a talk for the UCSF Office of Graduate Medical Education WAAAAY back in early 2010 on "There’s an App for That:  Key Smart Phone Applications for Surviving Residency". Somehow the lecture date has snuck up on me and it's next Tuesday! I thought it was a small gathering, but it turns out it's not. Plus, I keep getting school-wide emails reminding all the residents and fellows to attending!

In a mild panic, I'm asking for the collective group's help.

Audience: Medical students, residents, fellows across all specialties
Time allotted: 1 hour

Here's my brainstorming list of the best FREE apps. Remember, these apps should be useful not JUST for Emergency Medicine.

• Evernote 
• Dropbox
• Epocrates
• New England Journal of Medicine app (weekly podcast, images, videos)
• Eye Handbook
• Eye Chart
• Not really an app, but the camera feature can be useful in many scenarios. For instance, photograph and email a series of EKGs to the Cardiology fellow for a possible STEMI case. Or, take pictures of an intoxicated patient's massive facial laceration to prove that there is INDEED a large gash extending across the entire forehead.

Other apps worth purchasing:

• Papers
• PediStat

Anything others that you can suggest? I'm happy to give you credit for those that I mention in the talk. 

Trick of the Trade: Reducing post-LP headache risk

We often do lumbar puncture in the ED. Patients get warned about the potential of a post LP headache.

What is the prevalence of a post-LP headache?
The literature reports 15% of ED patients have a post LP headache.

How bad is it?
Most present in 3-7 days. Since the pain is postural, it impairs the patient's ability to perform activities of daily living (imagine trying to do everything lying down in bed!). Slim women aged 18-40 seem to be at the highest risk.

What will decrease incidence of post LP headache?
Pick the correct spinal needle.

The incidence of post LP headache:

• 20G cutting needle: 40%
• 25G cutting needle: 5%
• 22G atraumatic needle (smaller dural puncture, smaller CSF leak): 4%.

Trick of the Trade: 22G or 25G atraumatic spinal needle

The atraumatic spinal needles, also known as Sprotte needles, have a more blunt tip and often require a larger gauge needle to first puncture the skin. If using a 25G needle (which is a bit flimsy), I use a regular 18G needle to puncture the skin and soft tissue first (acting as a trocar), then I thread the 25G spinal needle through.

Hot off the press: A summary of EM content in social media

The ever-creative and ambitious masterminds at Life in the Fast Lane has just launched a new feature called LITFL Review. This weekly review will highlight all-things EM in the social media world. Do they ever sleep over there in Australia?! Do they somehow have 25 hours in their day?

This review is looking like it'll be the go-to site for weekly summaries of new EM and Critical Care topics on the web. I'm humbled to be on the list that they follow. I suppose I'll have to up my game. I'll surely be checking it out.

Some other sites that they are following:

• EM Crit Blog by Dr. Scott Weingart
• Emergency Physicians Monthly
• The Poison Review by Dr. Leon Gussow
• EMRAP Educators Edition by Dr. Rob Rogers
• ERCAST by Dr. Rob Orman
• Resus.ME by Dr. Cliff Reid
• MicroGnome by Dr. Tim Inglis
• Impactednurse by Ian Miller
• The Central Line
• EMRAP.TV by Dr. Mel Herbert

Article review: Teaching documentation on electronic medical records

Emergency departments and inpatient services increasingly are implementing electronic medical records (EMR) for patient care documentation. Students are infrequently taught how to document on EMRs, partly because some institutions bar students from typing on the official chart.

This commentary proposes using the RIME approach, made famous by Dr. Lou Pangaro. I reviewed RIME in an earlier post here. Briefly, you can categorize learners in the ED as a Reporter, Interpreter, Manager, and Educator.

Similarly you can evaluate a learner's ability to document in the EMR using a similar approach:

• Reporter: Enters clinical data accurately, avoiding cut-and-pasting elements
• Interpreter: Assesses/explains the data and incorporates into the EMR note
• Manager: Assimilates the data and articulates a logical management plan
• Educator: Modifies management plan based on evidence-based literature, clinical support tools, and patient preferences

Summary table from article 

(click to open larger version)

What is the appropriate skill level in EMR documentation for a third- or fourth-year medical student? 
According to the authors, MS3's should be proficient at being a Reporter, and MS4's should be proficient at being an Interpreter.

 

EMR proficiency chart from article 

(click to open larger version)

Reference

Stephens MB, Gimbel RW, Pangaro L. Commentary: The RIME/EMR Scheme: An Educational Approach to Clinical Documentation in Electronic Medical Records. Acad Med. 2011, 86(1):11-14. PMID: 21191202

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Paucis Verbis card: Sutures

Suturing is a common procedure performed in the ED, but we too often forget about the nuances of different suture materials. We get set in our practice patterns. This changed when our ED got the fast-absorbing gut suture for surface wounds, especially for pediatric patients. This makes a return visit for suture removal unnecessary because they quickly become absorbed over time. Increasingly, I have observed plastics surgeons using these for surface wound closure of the face and hands.

Has anyone else used absorbable sutures on the skin for wound closure?

With this new suture material in my armamentarium, I thought it'd be helpful to review suture types and suture removal times for non-absorbable sutures.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

EM-RAP Educator's Edition: Bedside teaching

This great EM-RAP podcast highlights Dr. Diane Birnbaumer (Harbor-UCLA) on the topic of becoming a great "one-minute teacher". This is a great resident/faculty development piece.

The 20-minute podcast include some great pearls and pitfalls. For instance, "resist the urge to spew" all your knowledge on the learner for each patient case. Give little nuggets of knowledge in digestible amounts.

The "one-minute teacher" for bedside teaching includes various microskills:

• Don't fill in the gap when silence occurs. For example, ask them "What do you think is going on?"
• Probe for supporting evidence to assess the learner's knowledge base.
• Do focused teaching.
• Tell the learner what s/he did well. Be specific.
• Give constructive criticism about mistakes. Ask the learner what s/he thinks how the shift went. Be specific about your comments.
• Make a learning plan.

The podcast includes an actual example where Diane demonstrates the "one-minute teacher" approach with a resident. 

Tricks of the Trade: Finding the wandering contact lens

Contact lens wearers are familiar with the phenomenon of the wandering lens. What should you do if you can't visualize the contact lens of a patient, who presents with a "lost contact lens" in the eye? You have the patient look in all directions and you evert the eyelid, but still no contact lens can be found. The patient swears that it's there because of the painful foreign-body sensation.

Trick of the Trade: Fluorescein dye
This trick was written by Dr. Ciro Paolillo from the Italian EM website MedEmIt by Dr. Gemma Morabito et al. No, I don't read Italian but my browser, Google Chrome can! The browser automatically recognizes that the text is not in English and asks me if I want it translated. While the translation isn't perfect, I can definitely understand the gist. The following is a summary.

Apply a drop of fluorescein dye in the eye. The contact lens will absorb the dye and appear yellow. This serves as a reminder that you should check to be sure that patients have removed their contact lens before instilling fluorescein. It permanently stains the lens.