What's your perfect idea for a medical app?

The American Medical Association (AMA) is harnassing the innovative power of the people in its "AMA App Challenge". What do you think would be the perfect app for medical students, residents, and/or practicing physicians in their day-to-day life?

This challenge is the perfect opportunity for all those with great app ideas but are too busy (or lazy) to do the technical, legal, and business groundwork to make the idea a reality. The down side is that once you submit the idea, AMA has full proprietary ownership of it.

The submission is pretty short and sweet:

• Name and brief summary of app idea (500 characters)
• More detailed description - list benefits and features (2000 characters)
• Who the app idea will appeal to and why (2000 characters)
• How your app idea is innovative/different (2000 characters)
• How your app fits with the AMA's mission to promote art and science of medicine and the betterment of health (2000 characters)
• Your background and medical/tech expertise (2000 characters)

Your app idea will be judged based on:

• 25%: Utility and appeal to target audience of physicians, residents/fellows, and/or medical students in their daily careers
• 25%: Fit with the AMA and its mission
• 20%: Innovativeness
• 20%: Suitability for app format
• 10%: Submitter's medical/technical background

Deadline: June 30, 2011

Two Grand Prize winners will be selected and each will receive a $1,000 AMEX gift card, a $1,500 Apple Store gift card, and a trip for 2 to New Orleans (for the AMA meeting in November 2011). One Grand Prize winner will go to a medical student, resident, or fescsllow. The other Grand Prize winner will go to a practicing physician.

Up to 8 Runner-Up winners will each receive a $100 AMEX gift card.

Thanks to iMedicalApps for the heads up on this!

Trick of the Trade: Steristrip-suture combo for thin skin lacerations

Lacerations of elderly patients or chronic corticosteroid users can be a challenge because they often have very thin skin. Sutures can tear through the fragile skin. Tissue adhesives may not adequately close the typically irregularly-edged laceration.

How do you repair these lacerations?
Do you just slap a band-aid on it?

Trick of the Trade:
Use a steristrip-suture combination approach.

Apply steristrips to reapproximate the wound edges. Reinforce the steristrips with suture material, as demonstrated in the article's figure. The steristrips provide an artificial layer of "skin", which sutures can use to reapproximate the wound edges.

My commentary:
While I haven't used the approach described in this article, I have, however, used steristrips positioned in parallel with the wound edge (rather than perpendicularly). Borrowing from the article's figure, I drew in the longitudinally-positioned steristrips to show how I've done it in the past. It works great. I don't use the perpendicular steristrips. I find that longitudinal steristrips provide even tensile strength along the wound edges.

Reference
Davis M, Nakhdjevani A, Lidder S. Suture/Steri-strip combination for the management of lacerations in thin-skinned individuals. J Emerg Med, 2011. 40(3), 322-3. PMID: 20880653
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Nancy Duarte at TedxEast: The anatomy of a great speech

Nancy Duarte, the author of "Resonate -- Present Visual Stories that Transform Audiences" and CEO of Duarte Design, recently gave a talk at TedxEast. The title was:

You Can Change The World

She passionately dissects the anatomy of world-class speeches. In the end, it's all about engaging and motivating the audience. In her 18-minute talk, she dissects Martin Luther King Jr's famous "I have a dream" speech and Steve Job's iPhone launch keynote speech.

In medical education, however, you can't exactly follow her template. You might be able to create a similar bimodal structure of what is and what could be by presenting cases and asking "what WOULD you have done?" and "what you SHOULD have done" questions to illustrate a gap. Also, you should consider sprinkling in stories of personal experiences throughout your talk to further engage the audience and solidify learning points.

Spend a few minutes and listen this engaging talk.

Article Review: Role of instructional technologies in medical education

A conference called "A 2020 Vision of Faculty Development Across the Medical Education Continuum" was held at Baylor College of Medicine in 2010. At this conference, experts convened to discuss the changing role of technologies in medical education.

Their conclusions were summarized in this Academic Medicine article, which discusses 5 trends and 5 recommendations.

Trends:

1. Explosion of new information: It has been postulated that the world's body of knowledge will double every 35 days by 2015. We are in an age of information explosion. Physicians will have to be able to process an ongoing onslaught of information throughout their career. Learning how to sustain lifelong learning will be critical. 
2. Digitization of all information: Medical records are slowly transitioning to an all-electronic format. Also in the age of Web 2.0, much of the digital content in health care are posted by the learners. Medical schools and residency programs will have to shift their approach to teaching,  disseminating, filtering, and supporting learning in this digital age.
3. New generation of learners: Learners in medical schools are primarily "digital natives". They have grown up with primarily digital textbooks and references. They have grown up with Facebook and Google. In contrast, educators are usually "digital settlers" -- not "born digital" but now "live digital".
4. Emergence of new instructional technologies: In the Web 2.0 age, there are a myriad of online tools such as blogs, wikis, podcasts, and virtual learning environments. 
5. Accelerating change: Computers will increasingly play a greater role in our everyday lives. I imagine something like the Minority Report movie. The future is almost here.

Recommendations:

1. Use technology to support learning: Technology shouldn't replace face-to-face learning but rather supplement areas which are better served using technology. Technology definitely helps with geographically distant learning groups, teaching deliberate practice using simulation, and individualizing learning plans.
2. Focus on the fundamentals: Keep your eye on the prize. Don't be tempted to use the new technologies for the sake of being current. First and foremost, focus on learner needs and the course objectives.
3. Allocate a variety of resources: Faculty should be taught how to effectively use instructional technologies in faculty development workshops. Furthermore, "e-learning specialists" should be available to help faculty create effective courses. These specialists include Web designers, videographers, and e-learning management system experts. 
4. Support and recognize faculty as they adopt new technologies: Institutional grants should be created to support faculty who want to adopt new instructional technologies. Furthermore, University promotion committees should value e-learning teaching modalities as academic scholarship. I wholeheartedly support this second statement-- my blog is still considered a "hobby" rather an academic pursuit. Good thing I love doing this.
5. Foster collaboration: We, as educators, need to share our ideas and resources nationally and internationally. Examples include the Health Education Assets Library (HEAL), MedEdPORTAL. 

Reference
Robin BR, McNeil SG, Cook DA, Agarwal KL, Singhal GR. Preparing for the Changing Role of Instructional Technologies in Medical Education. Acad Med. 2011 - in early press. PMID: 21346506
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Paucis Verbis: Chemical sedation for severe agitation

Haldol, Ativan, and Versed... oh my.

In the Emergency Department, some patients present very acutely and aggressively agitated. This is usually the result of illicit drug use or a schizophrenic who hasn't been taking medications (or both!). Fortunately, we have an arsenal of medications to help sedate the patient, as reviewed in a previous Tricks of the Trade post.

One study looked to answer the question of what single IM sedation agent is most effective, as measured by the shortest time to sedation and time to arousal.

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Nobay F, Simon B, Levitt M, Dresden G. A Prospective, Double-blind, Randomized Trial of Midazolam versus Haloperidol versus Lorazepam in the Chemical Restraint of Violent and Severely Agitated Patients Academic Emergency Medicine. 2004, 11(7): 744-9. DOI: 10.1197/j.aem.2003.06.015
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PollEverywhere: A cool real-time tool for lectures

Have you ever wanted to ask a quick question of clarification or make a quick comment during or at the end of someone's lecture?

I recently learned of PollEverywhere at the recent Council of EM Residency Directors conference when it was used during a lecture on Web 2.0 (how appropriate!). PollEverywhere allows audience members to use their mobile phone or laptop computer to vote and/or comment on questions posed by the speaker. Information can be send via text message, online, and even by Twitter!

You can equate this to having an Audience Response System (ARS) setup without having to purchase all of the hardware equipment, such as a receiver and individual remote "clickers".

Although most plans have a monthly service fee, there is a free plan option. I like free. This option allows you to pose one multiple-choice or free-text question and to get up to 30 responses. This can definitely get the job done for residency and medical student talks.

Here's the link to build a poll for free:
http://www.polleverywhere.com/my/polls/new

I do not have any financial affiliations with PollEverywhere. Just a fan.

Trick of the Trade: Benzoin for opening traumatic, swollen eyelids

Patients who sustain facial trauma often have swollen eyelids. They may be so swollen that it is impossible to pull back the eyelids for an ocular exam. You use one of our "Tricks of the Trade"ideas and attempt to "roll" the upper eyelid using the Q-tip trick (above).

Fresh blood on the face, however, makes the Q-tip a little slippery along the upper eyelid, preventing an adequate view of the eye itself.

Trick of the Trade:
Apply benzoin along the lower and upper eyelid to increase your traction.

• Clean and dry the lower and upper eyelid so that they are not bloody.
• Apply a thin layer of benzoin adhesive fluid along the eyelids, being careful not to contact the eye or eye lashes.  
• The dried benzoin allows easier traction when retracting the eyelids.
• Use your fingers or Q-tips to gently retract the eyelids.

Thanks to Dr. Duong for this great tip and the patient for consenting to have his photo taken for educational purposes.

Search for PubMed articles on the go

Great news! The National Library of Medicine has joined the mobile web app world. It has just created a new beta version of the Pubmed website for mobile app users.

http://www.ncbi.nlm.nih.gov/m/pubmed

This site allows users to perform basic PubMed search commands and to sort results based on "Free Full Text" and "Reviews" (see arrows).

Thanks to the folks at iMedicalApps for letting us know about the news.

Article Review: Barriers to effective teaching

I think there is no better or more rewarding job than being an educator, especially in the field of Medicine.

There are, however, significant financial, societal, curricular, and environmental barriers which prevent optimally effective teaching in Medicine. In a commentary piece in Academic Medicine, the authors review the barriers and some forward-thinking recommendations for our leaders in medical academia. While the focus of the article is on undergraduate medical education, many concepts apply to graduate medical education as well.

Recommendations:

1. Establish and measure desired education outcomes of graduates. We need to agree upon and articulate what common skills and knowledge we expect from our medical school and residency graduates. For instance, should ALL medical students be proficient in a lumbar puncture? There are differences in opinion.
   
2. Determine acceptable evidence of performance proficiency and use. "Longitudinal performance-tracking systems" should be in place to ensure learners achieve key benchmark goals.
   
3. Build systems into the curriculum that will increase the capacity for strong patient–learner and teacher–learner relationships. Medical students should establish strong longitudinal ties with faculty mentors and have early clinical learning experiences during medical school. Extrapolating this to the GME arena, residents should find faculty mentors and start building their career track.
   
4.  Involve other health professionals as collaborators in the education mission. This enhances interdisciplinary collaboration and communication, while also reducing the need for clinical faculty time.
   
5. Require systems that recognize and reward excellence in teaching and educational scholarship and hold faculty accountable for the quality and amount of teaching. Academic faculty are expected to teach, as part of their academic responsibilities, and should be held accountable. Also, faculty development opportunities need to be available to help substandard performers improve their skills.
   
6. Allocate adequate space, budgets for supplies, professional resources, equipment, and compensation to optimize the education mission. We need to invest more in our educators, who often are uncompensated for their time to teach medical students and residents.
   
7. Recruit educational specialists with the appropriate expertise to optimize faculty efforts as clerkship or residency directors, course directors, or teachers. Even our educational leaders need mentorship. We can always get better. At UCSF, we have the Office of Educational Research and the Academy of Medical Educators to help educators with problems, faculty development, and mentorship. Take a look at your institution to see what's available.
   
8. Develop a national or global health care professions institute whose aim is to advance the development of health professions educators and educational research. Medical educators do not have a national organization for the specific purpose of improving faculty development and the quality of educational research. A national organization might offer certificate or degrees upon completion of a series of workshops or courses (such as the Medical Education Research Certificate (MERC) program hosted by the AAMC). By bring physicians from across specialties and sites, this would enable easier coordination and collaboration for large-scale multi-institutional studies.
9. Increase grant dollar availability for educational development and research in health professions education at the federal and local level. Show me the money.
   
10. Create an international health professions education statistics database. This would expand beyond the US Department of Education's National Center for Education Statistics (NCES) to identify common educational issues on the global level.

Research
Darosa DA, Skeff K, Friedland JA, Coburn M, Cox S, Pollart S, Oʼconnell M, Smith S. Barriers to Effective Teaching. Academic Medicine. 2011 - in early release. PMID: 21346500

Paucis Verbis: Strength of diagnostic tests for cholecystitis

You have a 40 year-old man who presents to the ED for persistent right upper quadrant abdominal pain for 12 hours after eating a fatty meal. He has no fevers, nausea, flank pain, or dysuria. His physical exam shows no fever and only moderate tenderness in the RUQ without guarding. He has a Murphy's sign which is improved after a total of 8 mg of IV morphine. His laboratory results, which include a WBC, liver function tests, lipase, and urinalysis, are normal.

Can you safely say that the patient doesn't have cholecystitis? Can you discharge him for outpatient ultrasonography to assess for symptomatic cholelithiasis?

As bedside ultrasonography becomes more of a staple in Emergency Departments, it is easy to just perform the ultrasound yourself if such a patient presents. If you do not have an ED ultrasound available, however, you need to send this patient for a formal ultrasound because he is still very much at risk for cholecystitis despite having unremarkable lab tests and no fever.

JAMA published a meta-analysis of 17 studies on the test characteristics for cholecystitis. I found it odd that they defined a fever as temperature >35 Celsius. The best performing characteristic was a Murphy's sign, although the positive likelihood ratio (LR) slightly crossed 1.0 (0.8-8.6).

[MS Word] [PDF]

See other Paucis Verbis cards.

Trowbridge, R. (2003). Does This Patient Have Acute Cholecystitis? JAMA: The Journal of the American Medical Association. 2003; 289 (1), 80-86. DOI: 10.1001/jama.289.1.80
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Khan Academy: A glimpse at the future of education

A TED video posted this month caught my eye. The speaker was Salman Khan and the title was "Let's Use Video To Reinvent Education". Intriguing.

Salman Khan, while working as a hedge fund analyst, hit it big after he posted a few simple math tutorials on YouTube for his cousins. His tutorials went viral. Very intriguing.

He now has personally created and posted over 2,000 tutorials in the areas of math, science, and economics for K-12 graders. This is now known as the Khan Academy. It is a not-for-profit organization "with the goal of changing education for the better by providing a free world-class education to anyone anywhere". It has tremendous backing by Bill Gates and a $2 million dollar grant from Google.

This has flipped many classrooms around where they are now assigned videos to watch at home and then come to school to collaborate on homework. The videos are now accompanied with competency tests and merit badges for each successfully completed test. This allows for each student to customize his/her own pace of learning and for teachers to follow their progress. Instead of expecting students to pass a minimum overall standard, the Khan Academy approach "expects mastery". It's ok to fail and experiment around, as long as you eventually get it.

An inspiring glimpse at the future of education.

Trick of the Trade: Topical anesthetic cream for cutaneous abscess drainage in children

Abscess drainage can be painful and time consuming in the ED. Can this article help?

Trick of the Trade: 
Apply a topical anesthetic cream on skin abscesses prior to incision and drainage (I and D).

In this press-released article in American Journal of Emergency Medicine, the authors found that application of a topical 4% lidocaine cream (LMX 4) was associated with spontaneous cutaneous abscess drainage in children.

Study Design:

• Retrospective chart review of children presented with skin abscess to an urban ED.
• Excluded are pilonidal abscess, paronychia or abscess involving genitalia.
• A subset of 300 patients were selected (100 at each of 3 academic sites).

Data collection:

• The treating physician decided whether a topical anesthetic should be used.
• The sites used a topical lidocaine cream (LMX 4). The cream is applied on the abscess with an occlusive dressing for 30-40 minutes. They looked at abscess treatment and return visits.

Results:

• 169 children required treatment in the ED.
• 110 received topical anesthetic (younger, more MRSA, less surrounding cellulitis) and 59 did not.
• Mean abscess size was not different between the two groups: 3.4 ± 2.4 with topical anesthetic vs 4.0 ± 2.7 cm without topical anesthetic, p = 0.22).
• 26/110 (24%) abscesses with topical anesthetic spontaneously drained in the ED vs 0/59 (0%) without a topical anesthetic.
• For the the topical anesthetic group, 26/110 (24%) needed procedural sedation. In contrast, 24/59 (41%) abscess without topical anesthetic needed procedural sedation. (OR 0.45)
• 22% in the topical anesthetic group returned to the ED (2% needed intervention) versus 34% in the no topical anesthetic group (none needed intervention).

How would this change my practice?

I would consider using topical anesthetic cream prior to abscess drainage. Even though it might still need I and D, I might avoid a procedure sedation.

Study limitation
Because this study was a retrospective study, selection bias may have occurred. Specifically, providers may have preferentially applied topical anesthetic or chosen procedural sedation, based on undocumented characteristics. It was nice to see that mean abscess size was not different between the two groups.

Reference

Cassidy-Smith T, Mistry RD, Russo CJ, McCans K, Brown N, Capano-Wehrle LM, Drago LA, Vitale PA, Baumann BM. Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children. Amer J Emerg Med. 2010 - in press. PMID: 21129885
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Educational innovation: A collaborative "concept map" using Google Docs

(click to enlarge image)

A "concept map" is a graphical display of information. As a visual learner, I am drawn to this approach to displaying medical knowledge. So in my talk on "The Hot Joint: Septic Arthritis"at a recent residency conference, I experimented with a more active learning approach to my allotted lecture time. I assigned each resident with a laptop a focused question to answer, which is displayed in green font above. They had 10 minutes to find the answer online.

After building a basic framework on a Google Docs Presentation document, I left the majority of the document blank for the residents. All of the residents received the Google Docs link http://bit.ly/ijMONm and had access to edit the document any way they saw fit.

For the most part, I think the session was fun, interactive, and informative, but it definitely wasn't perfect.

Lessons I learned:

• 10 minutes is too short of a time for residents to answer their question. They probably needed more like 20-30 minutes to better research for the best answer. Also, I didn't factor in the slow wireless internet connection since everyone was online simultaneously. Unfortunately, I only had 55 minutes total for my entire talk. 
• I was surprised to find that many were not too familiar with Google Docs, despite most being Generation Y-ers. Well, now they are one step closer to familiarity.
• Because of the limited time and simultaneous publishing of content, the layout of the concept map wasn't very readable or user-friendly initially. Having a resident dedicated to cleaning up the layout helped. I put on the final editing touches after conference.
• It was helpful that I had a text area (Instructor Box), which was covered with a white box. This contained key images and text, in case the residents didn't find the best answer or image to key clinical questions posed. At the end of the talk, I removed the white box and made sure that we covered all of the key points.
• This teaching approach can be too non-traditional for learners. I should have spent more time talking about concept maps, why teachers SHOULDN'T be giving powerpoint-based talks, and the power of active learning. Fortunately, I think most of the residents were game to try this new educational innovation. While I generally don't pay attention to my evaluations, I'll see how my evaluations turn out...

What's great about using Google Docs to build a concept map:

• You can insert images onto the concept map by uploading a file or typing in the URL link of the file.
• You can enlarge the white canvas to any desired size to accommodate growing content.
• You can export the entire Presentation as a jpg, png, or pdf file.

It was also entertaining to watch residents try to work around each other's text. On the projector screen, you could see images and text travel across the screen to their intended destinations.

Article Review: Emergency physicians interruptions

What exactly do ED attendings do on shift? 

This novel prospective, time-motion study tracks the activities of ED attendings at 2 academic and 2 community sites. All sites used paper charting in the ED and computerized medical records for labs and radiology results.

METHODS
Trained observers recorded tasks in 1-minute increments over a 2-hour period. Three general categories were defined as:

• Direct patient care (lifting patients, bedside history/physical exam, direct interaction with patient, ordering tests or medications, interpreting ECG, performing procedures)
• Indirect patient care (charting, reviewing records, teaching learners, interpretation of diagnostic tests, talking with patient's friends/family; interacting with nurses, paramedics, consultants, ancillary staff)
• Personal activity (waiting, eating, social conversation with colleague, surfing the internet)

Specifically, the observers tracked "interruptions", as defined as an event that briefly required the attention of the attending but did not result in switching to a new task. This included:

• Listening to an overhead announcement
• Nursing inquiry about another patient
• Quick update from a learner

Also "breaks in task" were also tracked, as defined as an interruption that resulted in changing tasks. Examples included answering incoming telephone call, stoping a procedure to care for a cardiac arrest patient.

Additional data points tracked included:

• Distance walked
• Patients touched
• Handwashing
• Time sitting
• Maximum # of patients under care

RESULTS
There were 203 two-hour observation periods (160 at academic sites, 43 at community sites). A total of 85 physicians were observed.

• The majority of time was spent performing indirect patient care. The median time was 61 minutes (academic) vs 55 minutes (community) over the 2-hour period.
• The median time for direct patient care was 36 minutes (academic) vs 41 minutes (community).
• The median number of different individuals interacted with was 35 (academic) vs 23 (community). Wow, we really do interact with a lot of people in a 2-hour period. I just never realized.
• Hand-washing occurred a median of 2 times at both the academic and community sites.
• Physicians walked a median of 0.3 miles (academic) vs 0.17 miles (community). I can definitely attest to all the walking, since I wore a pedometer several years ago. I used to walk over half a mile per 8-hour shift.

The most interesting finding is that interruptions occurred a median of 12 times (academic) vs 6 times (community). Furthermore, 5 of the 12 (academic) and 2 of the 6 (community) interruptions resulted in a "break in task".

BOTTOM LINE
The data from this study provide many interesting discussion points. For instance, emergency physicians need to have strong communication skills, since we interact with so many different individuals. Furthermore, it would be interesting to repeat this study with the implementation of an electronic medical record system in the ED. Would it decrease some of the inefficiencies?

Interruptions are definitely a part of our everyday lives when working the ED. It's more frequent in an academic institution, presumably because we work with medical students and residents who have questions and updates. Because interruptions are associated with a higher risk for medical errors, greater stress levels, and impaired task performance, we need to teach attendings (and EM residents) how to minimize and cope with interruptions.  It would be great if we could wear a "Do NOT Disturb" hat when we are already overwhelmed.

Kudos to the research team for coordinating and completing such a Herculean study. Can you imagine following attendings around for a total of 406 hours and tracking minute-to-minute activities?

Reference
Chisholm CD, Weaver CS, Whenmouth L, Giles B. A Task Analysis of Emergency Physician Activities in Academic and Community Settings. Annals of emergency medicine. 2011 - in press. PMID: 21276642
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Paucis Verbis: Right and posterior EKG leads

A standard 12-lead EKG can be very telling for patients with chest pain or shortness of breath. A right ventricular (RV) and posterior wall infarct, however, can present very subtly. You can obtain special right-sided (V1R-V6R) and posterior leads (V7-V9), if you are concerned.

What are the indications for obtaining right-sided and posterior EKG leads?

Addendum 3/11/11:
Right sided EKG leads (V1R-V6R) are positioned in a mirror image fashion from the standard 12-lead precordial leads.

Posterior EKG leads (V7-V9) are applied by moving V4-V6 in the posterior positions.

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

Thanks to Caitlin for suggesting this topic!

[MS Word] [PDF]

See other Paucis Verbis cards.

EM-RAP Educator's Edition: Patient Handover

The latest podcast on EM-RAP Educator's Edition features our very own Dr. Stella Yiu (who is part of our blogging team!) and Dr. David Carr. The topic is on Patient Handover -- the transition of one physician to the next.

Take a listen to the 36-minute podcast. Some tips:

• Patient handover is a critical part of EM resident training. It takes practice. Signout rounds is a known high-risk time for errors.
• Be aware of the sign-out statement "... and there's nothing for you to do." You should still go check out the patient to corroborate.
• Consider calling a consultant before leaving your shift, if you would have called them regardless of the result of a pending study (eg. CT head, D-dimer). You know the patient much better than the oncoming new provider.
• Create a clear decision tree.
• Don't be afraid to restart your history and physical when something doesn't make sense or the clinical course changes. Don't rely solely on the previous provider's story.
• When signing out, try to anticipate "forks in the road" and highlight the high-risk patients.

Trick of the Trade: Heat it up!

What is it about heat that makes everything feel better? Fireplace, hot tub, heat packs, electric blankets, and hot chocolate have got to be the best inventions EVER.

How can we apply this in Medicine?

Trick of the Trade: 
Warm anesthetic solution prior to injection.

A meta-analysis of literature (18 studies) has shown that warming anesthetic fluid prior to injection results in less pain, as compared to room-temperature anesthetic. So while you are gathering and preparing the rest of your equipment, partially fill a small tub with warm water and let your lidocaine or bupivicaine bottle sit in it. It only takes a few minutes to warm the solution. Rubber duckies are optional. 

Thanks to Dr. Gemma Morabito for letting me know about this article. Here's her photo of running warm water over the anesthetic vial before the procedure. Check out her Medicinadurgenza site post. If you are using Google Chrome, you can set the browser to translate the entire site from Italian to English.

Reference

Hogan ME, Vandervaart S, Perampaladas K, Machado M, Einarson TR, Taddio A. Systematic Review and Meta-analysis of the Effect of Warming Local Anesthetics on Injection Pain. Ann Emerg Med. 2011 - in press. PMID: 21316812

Finding the right journal for your manuscript

When writing a manuscript, how do you choose what journal to submit to? You should factor in the journal's impact factor and your manuscript content.

At the recent CORD Academic Assembly meeting, I learned of a website which helps you decide your journal.

JANE: Journal/Author Name Estimator

By entering keywords or even your entire abstract, the site will compare your text to words from millions of articles from Medline journals. The best matching journals will be listed in descending relevance.

If I ever get around to finishing my manuscript on my study on the impact of ED crowding on ED faculty teaching time, my best choice of manuscript would be Annals of Emergency Medicine. I got the list below after entering "crowding emergency department education" in the search box.

 
The site is worth a look-see.

Article review: Faculty skills impact their rating of residents

One of the frustrating things about reviewing evaluation cards of medical students and residents is the degree of variability in how faculty rate them. There are some faculty who can be generalized as "hawks" and "doves"-- really tough or really benign graders, respectively.

Why do faculty rate the same learner differently? This has been a topic of much debate over the years. In this study in Academic Medicine, Dr. Kogan et al make an interesting hypothesis:

• Faculty with better clinical skills and experience would be more stringent raters.
• These relationships would be stronger in competency-specific domains ("i.e., faculty with more complete history-taking approaches would rate history-taking more stringently").

Methodology:

• 48 faculty volunteered to participate in this study (paid)
• Each faculty member completed eight 15-minute standardized patient (SP) encounters on common outpatient scenarios.
• The standardized patients scored each faculty member using checklists on history, physical exam, counseling, interpersonal, and professionalism skills.
• Subsequently, each faculty member reviewed 4 videos of residents participating in SP encounters.
• Each residents was graded using a mini-Clinical Evaluation Exercise (CEX) tool, which assessed 7 competencies on a 9-point scale (interviewing, physical exam, humanistic/professional qualities, clinical judgment, counseling skills, organization/efficiency, overall competence)

Results:
Before I present the results, let's review "linear correlation coefficient", usually designated as "r". This measures the strength and direction of a linear relationship between two variables. Generally a r greater than 0.8 or less than -0.8 suggests a strong correlation.

• There was a significant negative correlation between faculty's history-taking scores and their ratings of residents in interviewing skills (r= - 0.55) and organizational skills (r= - 0.35). This means faculty who were better history-takers were more stringent raters in the areas of interviewing and organizational skills.
• Faculty with better process performance scores (eg. not interrupting patients in the chief complaint, using open-ended questions, avoiding jargon) were more stringent raters in the areas of interviewing, physical exam, and organization (r= - 0.41, - 0.42, - 0.36, respectively).

Bottom Line:
This study shows that variability in learner assessment is dependent on the faculty's clinical skills. Should we only have our most skilled faculty evaluate our learners then? This study highlights the importance of faculty competencies in residency competency assessment.


Thinking about myself, I know that I usually give learners relatively high scores unless they are blatantly poor performers. I'm more of a "dove" than a "hawk". So, what does that say about me? Can I extrapolate that I'm not as clinically skilled as my peers? Wait, I'm offended by the implication...


References
Kogan JR, Hess BJ, Conforti LN, Holmboe ES. What drives faculty ratings of residents' clinical skills? The impact of faculty's own clinical skills. Academic Medicine. 2010, 85:S25-S28. PMID: 20881697
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Peak into the CORD Academic Assembly: A first-hand account

Be a fly on the wall!

March 3rd kicks off the 3-day CORD Academic Assembly in San Diego where educators, residency directors, and clerkship directors all assemble for a big pow-wow on all-things education in EM.

Keep checking back here for real-time accounts of the conference as I bounce from room to room and lecture to lecture. The most recent post will be at the top.



FYI, Dr. Horng emailed me the link to his CORD handout from the "Web 2.0" didactic session. Thanks!

Trick of the Trade: Website resource on HIV medications

At our department's first annual UCSF High Risk Hawaii Conference 2 weeks ago, Dr. Rachel Chin taught about complications from all of the HIV drugs on the market now. It's a virtual alphabet soup: EFV, TDF, FTC, oh my. How do you keep track of them all?

Trick of the Trade:
HIV InSite website

The website is actually hosted and constantly updated by the Center for HIV Information at UCSF. Take a few minutes to browse through the extensive website: http://hivinsite.ucsf.edu/InSite

Specifically, I find the following sub-links most useful in the Emergency Department:

• Side effect profile of antiretroviral (ARV) drugs: http://hivinsite.ucsf.edu/InSite?page=ar-05-01#S2X. For instance, this is the side-effect profile for Indinavir:

• ARV drug profiles: http://hivinsite.ucsf.edu/InSite?page=ar-drugs
• Interactions with other ARV and non-ARV medications: http://hivinsite.ucsf.edu/InSite?page=ar-00-02

Hot off the press: Clinical practice guideline for ketamine in the ED

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction.

Hhhmmmm...how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions!

Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was just published.

This practice guideline was updated from a previous 2004 version because of new research that proved/disproved the way ketamine was being utilized. It was compiled by four physicians that are experts in the field of ketamine sedation, two of which wrote the 2004 practice guideline. Updated research was found by performing a MEDLINE search from January 2003 to November 2010 using the search term "ketamine".

Highlights:

1. Adults have been included in the 2011 guidelines.

2. Adjunctive medications

• Prophylactic ondansetron can help reduce vomiting. The number needed to benefit = 9.
• No need to co-administer atropine or glycopyrrolate for oral secretions.
• Prophylactic midazolam 0.3 mg/kg may prevent recovery reactions in adults (but not children). The number needed benefit = 6.

3. Contraindications

• Age < 3 months because of risk of airway complications
• Known or suspected schizophrenia (even if currently stable)
• Head trauma has been removed as a contraindication.

4. Route of administration

• IV administration appears to be preferred over IM, because of faster recover and fewer episodes of emesis.
• IV route: Peak concentration and onset = 1 min, duration of dissociation = 5-10 min, time from dose-to-discharge = 50-110 min
• IM route: Peak concentration and onset = 5 min, duration of dissociation = 20-30 min, time from dose-to-discharge = 60-140 min 

5. Complications

• Laryngospasm has been reported to be around 0.3%. What do you do when this happens? You'll just have to read this previous post to find out.

Reference

Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency medicine. 2011 - in press. PMID: 21256625
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