Pneumonia is a common cause for ED visits. How do you decide on whether the patient can be managed as an outpatient or inpatient? To supplement your clinical judgment, many clinicians use the Pneumonia Severity Index (PSI) score.
Have you heard of CURB-65, supported by the British Thoracic Society? What about SMART-COP, which is meant to help you predict if your patient will need Intensive Respiratory or Vasopressor Support (IRVS)?
It's worth a quick review.
Feel free to download this card and print on a 4'' x 6'' index card.
Presentations are traditionally given using Powerpoint. Keynote is prettier alternative to Powerpoint but is only Macintosh-compatible. Both have the same antiquated structure such that content is presented only linearly.
The hottest presentation tool now is Prezi, a web-based tool, which allows the viewer to zoom in and out of sections. The visuals are more of a conceptual map of the content, where the viewer or speaker can zoom around any desired topic. Because it's online, you can easily embed YouTube videos.
Take a look at this Prezi demo advocating it as a tool for teaching.
To navigate, you can click on the gray arrows at the bottom to advance forward or backward, as pre-programmed. Alternatively, you can drag the display using your mouse. Or you can zoom in/out using the + or - tools on the right.
Google Docs is constantly improving and growing. One of the cool features is that you can embed any document within your blog. Whenever you edit the Google Docs document, it automatically updates in your blog.
How do I do this?
Within your document in Google Docs, click on the upper right "Share" button and select "Publish to Web".
In the pop-up screen, select "Start Publishing".
Copy and paste the provided HTML code in your blog.
With a little HTML editing, you can make the optimize the margins bigger than the teeny preset dimensions. To change the margins to 440-pixel width and 500-pixel height, add the extra text (in bold) into your code as follows:
And ta-da! Embedded is my handout from a recent talk on mobile apps in Medicine.
A new CME publication has emerged from the publishers of Emergency Medicine Practice and Pediatric Emergency Medicine Practice called EM Critical Care. This new publication is specifically geared towards manging critically ill patients in the ED. There will be 6 issues per year with each issue offering 3 AMA PRA Category 1 credits. Although it has not yet been released, it appears to have an impressive editorial board including Emanuel Rivers, Michael Gibbs, Benjamin Abella and Robert Arntfield. Oh, and did I not mention Scott Weingart from the EMCrit Blog? If it is anything similar to it's predecessors, it is guaranteed to be a hit!
In a Research Letter in JAMA, Dr. Chretien et al describe the profile of physicians in the Twitter universe, specifically focusing on professionalism.
Self identified physician
At least 500 followers during May 1-31, 2010 (Whew, I only have 309 followers.)
Posted a tweet within last 6 months
A total of 260 physicians were studied.
6.2% were from Emergency Medicine.
15% (most) were from Surgery and its subspecialties.
76% were from the United States.
Three physicians independently coded the 20 most recent tweets from each account (total n= 5,156) for unprofessional content. There were 144 (3%) unprofessional tweets from 27 users:
55 (1%) - possible conflict of interest, advocating for non-standard therapies
38 (0.7%) - potentially violation of patient privacy
33 (0.6%) - profanity
14 (0.3%) - sexually explicit material
4 (0.1%) - discriminatory statement
25 of 27 (92%) of users were identifiable
The authors conclude that, although rare, there should be more physician accountability and guidelines in the age of social media. This is even more true, since I just discovered that all tweets are archived by the Library of Congress!
Take a look at your most recent tweets. How would they have performed if you were included in this study?
Reference Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA: The journal of the American Medical Association. 2011. 305(6), 566-8. PMID: 21304081 .
Dr. Rob Orman of ERCast blog fame emailed me last week about creating a pocket card on Suicide Risk Stratification. In many community ED's, risk assessment is done by the emergency physician. I'm lucky where I work, because we have a 24/7 psychiatric ED, which consults on suicidal patients in the "medical ED".
In the end, assessment is primarily based on physician judgment, because there's no great clinical decision tool, rules, or scores to assess risk. Rob has created his own mnemonic to help you ask the right questions in assessing a suicidal patient. This is a sneak peak into a larger article that Rob is planning to unleash on the world on suicide assessment. Based on his review of the literature and own clinical experience, the mnemonic is: TRAAPPED SILO SAFE.
"Risk factors" which increase a patient's risk for committing suicide in the near future.
"Protective factors"which decrease a patient's risk for committing suicide in the near future.
Feel free to download this card and print on a 4'' x 6'' index card.
* Updated 3/8/11: Added extra "A" to include "Access to Means" as a risk factor.
Ever since my post about the top medical apps, I have been inundated with people asking me to review their apps.
One has stood out.
Medibabble is a real-time medical translation app and is now available for FREE. It was created by two innovative UCSF medical school graduates, Dr. Alex Blau and Dr. Brad Cohn. This app contains an extensive preset list of history questions and physical exam commands. When you click on a sentence, the app will translate and speak the sentence in one of 5 languages (Spanish, Cantonese, Mandarin, Russian, and Haitian Creole).
Take a few minutes to download all of the free languages onto your device. It only comes with Spanish pre-installed. There is a FAQ page at www.medibabble.com. The app is only available for the iOS platform currently.
Does your Emergency Department have computerized spectrophotometric catheters to measure continuous central venous oxygen saturation (ScvO2) in early goal directed therapy (EGDT) for severe sepsis? That's what was used in the original Rivers' EGDT study.
I've never even seen one before.
Many emergency physicians are getting around not having the specialized equipment issue by obtaining intermittent venous blood gas measurements off of a central venous line.
But what if you had a 30 y/o woman with early pyelonephritis/urosepsis who has severe sepsis by definition? She's got 10 peripheral lines (I'm exaggerating, of course), a normalized blood pressure with early IV fluids, and appears non-toxic. Her lactate, however, is 9! Do you really need a central line? My gut says no, but the EGDT protocol says yes -- for the purpose of CVP and ScvO2 measurements.
Trick of the Trade:
Use a less-invasive approach where bedside ultrasound and serial venous lactate levels replace central venous lines and ScvO2 measurements, respectively.
Last year, JAMA published a landmark study showing that lactate clearance of ≥10% over the first 2 hours is "not a worse measurement" than ScvO2≥70%. This double-negative statistical speak came about because it was a non-inferiority study.
So how does this affect the original Rivers protocol? To review, here's the original protocol, which I posted about earlier:
(click to view larger image)
In the less invasive model:
Fluid resuscitate through peripheral IV access instead of a central line.
Follow volume status either with a bedside ultrasound or urine output.
Follow venous lactate levels at time 0 and 2 hours. If the lactate clearance is ≥10% over these 2 hours, you should follow the algorithm as if the ScvO2≥70%. That means no need for immediate transfusion or vasopressor agents.
How do you know when you have adequately volume-resuscitated a patient using bedside ultrasound? Measure the IVC diameter about 1-2 cm from the right atrium junction.
If the IVC diameter ≤1.5 cm and has ≥50% collapse with inspiration, the patient has a very low CVP.
If the IVC diameter is at least 1.5 cm and has minimal collapse with inspiration, the patient is euvolemic. Move to the next step -- assessing the MAP.
This doesn't mean that all EGDT patient should have ONLY peripheral lines. Persistent hypotension, a non-clearing lactate level, and/or clinical toxicity warrant more invasive monitoring and management.
Scott Weingart has an in-depth, 21-minute podcast about the JAMA article and noninvasive approach to sepsis: Podcast link. Scott also briefly interviews Dr. Alan Jones (Carolinas Medical Center), the first author of the study, in the podcast.
Reference Jones AE, et al; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA : the journal of the American Medical Association.2010, 303(8), 739-46. PMID: 20179283 .
In its third official year, the Clerkship Directors in Emergency Medicine (CDEM) organization is still growing strong. It all started with six of us at an informal dinner in Boston about 5 years ago. And now the organization has grown so large that it is now for the first time offering annual awards to its members.
Know an award-worthy educator? Nominate him or her!
CDEM Clerkship Director of the Year Award
This award recognizes an Emergency Medicine Clerkship Director that has made significant contributions to either a 3rd or 4th year EM rotation. To be eligible for this award, the nominee must currently be a Clerkship Director of a mandatory, selective or elective rotation and have served in that role for a minimum of 5 years. This award is presented at the annual CDEM meeting.
CDEM Young Educator of the Year Award
This award recognizes a medical student educator at the Clinical Instructor or Assistant Professor level and less than 10 year from residency completion who has made significant contributions to teaching and educating medical students. This award is presented at the annual CDEM meeting.
CDEM Distinguished Educator Award
This award recognizes a medical student educator at the Associate Professor or Professor level who has made significant contributions to and has demonstrated sustained excellence in teaching and educating medical students for 10 or more years. This award is not presented annually; rather, it is bestowed on special occasions.
CDEM Award for Innovation in Medical Education
This award recognizes a medical student educator at any faculty rank who has made a significant and innovative contribution to undergraduate medical education. This award is presented at the annual CDEM meeting.
By learning about our differences, we can learn to appreciate and better communicate with those who are different from us.
The same falls true for working with residents and faculty from different "generations", as defined as traditionalists, baby boomers, generation Xers, and millennials.
This literature review and consensus document is quite extensive and even comes in 2 parts in Academic Emergency Medicine. There is a great summary table of the generational differences in personal, work, and educational characteristics, communication styles, and technology.
Think of faculty who fit in these age groups. Do they fit their generational stereotype?
Traditionalists (born 1925-1945)
Personal characteristics: Loyal, reluctant to change, dedicated, value honor and duty, patriotic
Work characteristics: Value hierarchy, loyal "company man", job security
Education characteristics: Process oriented
Communication style: Formal
Technology: Tend not to understand
Baby Boomers(born 1945-1964)
Personal characteristics: Optimistic, desire for personal gratification, highly competitive
Work characteristics: Workaholic, competitive, consensus builder, mentor
Education characteristics: Learner depends on educator, lecture format, process-oriented
Communication style: Diplomatic
Technology: Not particularly techno-saavy
Generation Xers (born 1964-1980)
Personal characteristics: Independent, self-directed, skeptical, resilient, more accepting of diversity, self-reliant
Work characteristics: Value work-life balance, comfortable with change, question authority
Education characteristics: Independent learners, problem-solvers, desire to learn on the job, outcome-oriented
Communication style: Blunt
Technology: Interested and facile
Millennials (born 1980-1999)
Personal characteristics: Optimistic, need for praise, collaborative, global outlook
Work characteristics: Team-oriented, follows rules and likes having structured time, career changes
Education characteristics: Team-based learning environment, turn to Internet for answers, outcome-oriented
Communication style: Polite
Technology: Very saavy, technology is a necessity
The authors give multiple examples where generational differences come to light but none more so than in mentorship within the academic department.
Traditionalists view mentorship as a more formal process, where feedback is necessary only to provide criticism or suggestions for improvement.
Baby boomers also view mentorship as a "top down" process. They are ok with infrequent interactions.
Generation Xers and Millennialsprefer mentorship as a more "peer to peer" process with more frequent interactions. They value the personal relationships and the opportunity to collaborate in creative solutions. Because of their stereotypical distrust of authority, however, they may inadvertently sabotage their relationship with their mentors. Distrust sometimes is misinterpreted as a general lack of respect.
To overcome these differences, mentor-mentee pairings should take into consideration gender and shared views about goals, work/life balance, and experiences. Early discussions in a mentorship relationship should discuss generational differences and how each envisions the ideal mentor-mentee relationship to be. The pair should agree upon and adopt a collaborative, shared communication approach with frequent feedback.
So much more in this article... Take a read.
Mohr NM, Moreno-Walton L, Mills AM, et al. Generational Influences in Academic Emergency Medicine: Teaching and Learning, Mentoring, and Technology (Part I). Acad Emerg Med. 2011, 18:190-9, 10.1111/j.1553-2712.2010.00985.x .
A 50 year-old woman, who presented to the ENT clinic for followup check of a facial fracture, has a blood pressure of 210/100. She is asymptomatic and in no pain. She gets referred immediately to the ED for care.
Now you see her in your ED. What next?
There is a lot of controversy whether you should treat or not treat asymptomatic hypertension in the ED. The ACEP Clinical Policy says that there is no need to immediately reduce an asymptomatic patient's blood pressure. With "close followup", they can be referred to their primary care physician.
With so many patients being uninsured or unable to access their primary care physician on short notice, many emergency physicians like myself are slowly moving towards starting antihypertensive medications for them.
If you do decide to start an antihypertensive, which medication do you choose? This Paucis Verbis card is based on a 2009 Cochrane Review, and summarized in American Family Physician in 2010. The blue numbers denote a Risk Ratio (RR) which cross 1, meaning that there is no benefit. The red numbers denote a RR < 1, meaning that there IS a benefit.
A low-dose thiazide, such as hydrochlorothiazide 12.5-25 mg po daily, is a safe and effective choice.
Feel free to download this card and print on a 4'' x 6'' index card.
References Quynh B. Cochrane for clinicians. First-line treatment for hypertension. Amer Fam Phys. 2010, 81(11), 1333-5. Mensah G, Bakris G. Treatment and Control of High Blood Pressure in Adults. Cardiology Clinics. 2010, 28(4), 609-22. ..
EMCast - Monthly podcast interviews with Dr. Amal Mattu through Emedhome.com ($99 annual subscription)
CDEM Curriculum - Resource put together by CDEM for medical students which includes essentially an online textbook in EM (free). Rob even put in a plug for my Digital Instruction in Emergency Medicine (DIEM) online simulation cases. I'm not actually done with all the cases, as Rob suggests! Only the first case on Chest Pain is done thus far... Ack! I better get crackin' now.
Spend a high-yield 25 minutes listening to Rob's take on need-to-know educational resources in EM.
A health care worker hurried in to the ED after being poked with a needle.
'It was an old 18G needle with dried blood', she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, 'What does very low risk mean?'
Is there another way to covery risk for patients?
Trick of the Trade: Convey probabilities with everyday risks.
This article uses a risk stratifying tool to convey probabilities that compare to everyday risks such as flying, cancer diagnosis, having an MI, etc. Below is the calculation tool from the paper.
Using this tool, the risk of contacting HIV for this patient would be:
5/ (1000 x 100 x 100) = 1/ 2,000,000
According to the everyday risk table in the article, this is similar to the risk of dying in the next 12 months from lightning. You left her to decide on PEP.
As the author pointed out, the risks cited are probabilities instead of exact measurements. This is an important caveat.
I find this helpful to provide context, especially for those who have difficulty deciding on PEP.
Vertesi L. Risk Assessment Stratification Protocol (RASP) to help patients decide on the use of postexposure prophylaxis for HIV exposure. CJEM : Canadian journal of emergency medical care. 2003, 5(1), 46-8. PMID: 17659153
Many academic Emergency Departments are staffed by non-EM residents. Dr. Amer Aldeen and his super-star team from Northwestern created NURRC Modules (Northwestern University Rotating Resident Curriculum). These modules allow the off-service residents, who all have different schedules, to learn key EM-based topics at their own leisure and convenience.
The positive effect of the curriculum on the off-service residents' medical knowledge was recently published in Academic Emergency Medicine: Read my review.
NURRC Video Modules:
ENT and Ophthalmology Emergencies
Obstetrics and Gynecology Emergencies
Trauma and Wound Care
Thanks to the team for agreeing to make these videos free for everyone to use.
I hope I wasn't too pushy or forward in asking for the videos... and then asking if I could post then all on YouTube! Such a great resource shouldn't live behind closed doors. I'll post the other 3 videos once I receive them from Amer.
It is 2 a.m. You, the resident, have just spoken to your staff/attending, who told you to do a task. You have seen one, but don't feel comfortable doing one independently.
Will you tell your staff/attending about how you feel?
What if the patient did poorly after that?
This study examines the perception of EM trainees of their competence and adverse events and how they feel about reporting them.
Anonymous web-based survey sent to all trainees from 9 EM programs in Canada outside Quebec.
37.3% trainees responded.
40% trainees felt they had minimal supervision when doing a task that they did not feel safe about.
Most 'unsafe' tasks included providing care overnight, admission decision or procedures.
When feeling incompetent, a third of trainees will not report this to their staff.
Barriers include worry about loss of trust, automony or respect.
64% trainees felt responsible for contributing to adverse events.
Most relate to procedures - chest tubes, central lines, paracentesis.
Majority, but not all, reported the most serious events to the staff.
Barriers include fear of appearing incompetent and humiliation.
How would I change my teaching practice
Ensure trainees feel safe. Maybe do a dry run of central line insertion/break bad news prior.
Encourage trainees to voice their discomfort. They are learning, not just working.
Discuss adverse events and medical errors with trainees.
Reference Friedman S, Sowerby R, Guo R, Bandiera G. Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey. CJEM: Canadian journal of emergency medical care. 2010, 12(6), 491-9. PMID: 21073775
Medgadget annually hosts a contest for the best medical blogs. It's the Superbowl of blogs.
Our blog was nominated for the Best New Medical Blog last year, but got our butt kicked.
This year, we're honored to be a finalist in the Best Clinical Sciences Blog category. That's the great news. Unlucky for us, we are in the same category as the juggernauts EMCrit (also nominated in the overall Best Medical Blog category) and Resus.M.E. I do love the fact that the EM specialty is dominating with 3 finalists in this list of 5.
With all of the amazing, sunny weather here in California, I feel (briefly) terrible for all those braving the snowpocalyptic conditions across the United States. So, in honor of all those bundled up and shivering, I wanted to review the management of accidental hypothermia.
Tip: Avoid jostling the hypothermic patient too much because of myocardial irritability. Don't send your patient into an arrhythmia.
Feel free to download this card and print on a 4'' x 6'' index card.
In his talk (subtitled "School Sucks"), Northwestern University Physics Professor Dr. Tae describes how he would improve math and science education. While this is directed at college studies, some of the concepts are applicable to teaching Emergency Medicine.
He shares a lot of great insight, but I wanted to focus on one concept in particular:
The secret to learning = "Work your ass off until you figure it out."
Dr. Tae demonstrates this as we watch him make 57 failed attempts trying to learn a new skateboarding trick before finally being able to successfully complete it on the 58th. In order to master this new skill, he had to actively struggle with it until he succeeded. He contrasts this with lectures where students "just sit there" passively, learning very little.
Clinical decision making is a skill, much like skateboarding, and our job in teaching this may be to let the students do most of the work. We're only there to offer guidance and point them in the right direction when necessary. So how can we challenge our students to struggle and fail until they ultimately figure it out?
Share your thoughts and ideas in the comments. Thanks!
Patients with a hairy chest may require little patches of hair to be shaved when applying EKG leads. This allows the leads to stick firmly to the chest. Loose leads will result in either an artifactual signal or no signal at all on the EKG machine.
How can you obtain an EKG without shaving little patches on the patient's chest?
Trick of the Trade: Cover EKG leads with damp gauze
Water maximes the contact surface area between the EKG lead and the patient's skin. The water easily conducts the cardiac electrical signal.
Generously soak gauze with water.
Apply gauze over each EKG lead where it contacts hairy skin.
He is an Assistant Professor of Emergency Medicine and Clerkship Director at Rush University Medical Center in Chicago, IL. Rahul has led the charge in building CDEM's educational site at www.cdemcurriculum.org, which essentially is a free online textbook for students on their EM rotation. His amazing technological saavy and passion for education in EM make him a perfect fit on our blogging team. I've been begging him to join us for over a year. We're lucky to have him!
Wednesday's post is his first (of hopefully many).
Well I finally took the leap and am primarily relying on my iPhone to look up medication doses, which I don't know off the top of my head. Gone are the days of purchasing Tarascon's pocket Pharmacopoeia every few years or so.
I still haven't settled on which I like more. Both are free. Both are available on multiple platforms, including iOS, Blackberry, and Android. Both have some unique features which I find useful.
Common strengths for both apps:
Easy to find drug you are looking for. Epocrates has a Search screen as the home page. Micromedex has a Search screen and alphabetical list of medications as the home page.
Dosing adjustments based on renal and hepatic function
Adult and pediatric dosing recommendations
Safety information with preganancy and lactation
Unique strengths of the apps:
Includes toxicology information for all the medications (what to do in case of an overdose)
I have heard that this Thomson Reuters app has been more peer-reviewed and accepted as a very reliable resource, especially for pediatric dosing.
Free from obvious advertisements (which is sometimes seen in Epocrates via the Doc Alerts)
Has pricing information
Allows user to identify unknown pill based on pill characteristics (color, shape, etc)
Ability for you to take notes on the app
They both will likely answer 99% of what you are looking for from a drug-prescribing perspective. So, which do you prefer and why?