Paucis Verbis: Fibrinolytics for PE

When would you give fibrinolytics for a 

Pulmonary Embolism?

This Paucis Verbis card summarizes recommendations found in Circulation's recently published Scientific Statement from the American Heart Association. Although it is rare to give fibrinolytics for a pulmonary embolism (PE) in the Emergency Department, it is important to remember when lytics are indicated.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Jaff MR, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830. Pubmed.
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New guest blogger: Dr. Hans Rosenberg

Dr. Hans Rosenberg

Let's make it official. Dr. Rosenberg has been contributing great content for this site. We're honored to have him officially join our blogging team!

Dr. Rosenberg did his residency at the University of Ottawa, graduating in 2009.  He now works at the Ottawa Hospital Emergency Department as a Consultant Staff Physician and is an Assistant Professor at the University of Ottawa.  His interests in medical education are specifically related to our interaction with technology and how we use it to learn, educate and improve our practice of Emergency Medicine.

Inspirational graduation speech by Conan

I found this inspirational 2011 graduation speech by Conan O'Brien at Dartmouth College. It is a great mix of silly, witty, inspirational, and profound. Check it out. For those in Medicine and medical training, your dreams may change over time... and that's ok.

"Your perceived failure can become a catalyst for profound reinvention."
-- Conan O'Brien

"No specific job or career goal defines me, and it should not define you."
- Conan O'Brien

Trick of the Trade: Making a beanie hat

Scalp lacerations are a common condition in the Emergency Department. Some require no bandage over once the injury is repaired. Because the scalp is so vascular, others require a pressure dressing over the site to minimize hematoma formation.

How do you bandage these patients? It is difficult to secure any wrap or square gauze over the site, because the head is round and the hair is slippery.

Trick of the Trade:
Make a snug-fitting beanie hat using tubular gauze.

• Find the appropriate size tubular gauze. It should fit snuggly over the patient's head when fully stretched open. Start with a 1-foot long piece of tubular gauze. Tie a knot on one end. This will sit at the vertex of the patient's scalp.

• Create 2 tails by cutting longitudinally along the tubular gauze.

• Pull the tubular gauze over the patient's scalp. Usually patients won't look this giddy-happy during this process.

• Secure the two tails under the patient's chin.

This technique allows you to rest several layers of 4x4 inch gauze over the laceration site as pressure dressing. The tubular gauze stabilizes it in place without any tape.

Thanks to Dr. Eric Silman (UCSF-SFGH EM chief resident) for the idea and photos!

SAEM 2012 Consensus Conference: Education Research in EM

It has just been announced that the upcoming 2012 SAEM annual meeting will feature a full-day Consensus Conference on Education Research in Emergency Medicine. In the past, Consensus Conferences have focused on such areas as "Interventions to Assure Quality in the Crowded Emergency Department" and "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise".

There's introductory information on the SAEM Facebook page. The format is a bit cluttered, so I am reposting here below:

 2012 Academic Emergency Medicine Consensus Conference

“Education Research in Emergency Medicine:

Opportunities, Challenges and Strategies for Success”

The 2012 Academic Emergency Medicine Consensus Conference, “Education Research in Emergency Medicine: Opportunities, Challenges and Strategies for Success” will be held on May 9, 2012, immediately preceding the SAEM Annual Meeting in Chicago, Illinois.  Original papers on the conference topic, if accepted, will be published together with the conference proceedings in the December 2012 issue of Academic Emergency Medicine.

A divide has traditionally existed in academic medicine between the educator and the researcher.  The goal of this conference is to bridge this gap, by exploring the principles that guide these two allied disciplines to create a unified focus on education research science that will benefit our teachers, our learners and ultimately our patients.

Emergency medicine (EM) educators have long perceived the need for better research to guide the frequent challenges encountered in the academic environment.   These include identifying best practice teaching methods, validating assessment tools, evaluating competency, and preventing cognitive errors.  Efforts to address these challenges have begun; however the historical use of suboptimal study designs, subjective outcomes, small samples sizes, and lack of expertise in methods useful in other domains can limit the success of education research studies. A coordinated agenda for EM education research is needed to address these topics and streamline our research efforts.

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project now mandates that training programs demonstrate the effectiveness of educational interventions and show evidence of trainee aptitude and achievement in the core competencies.   The American Board of Emergency Medicine (ABEM) now requires its diplomats to provide evidence of Assessment of Practice Performance in order to receive continuous certification.  These and other requirements highlight the current paucity of available evidence to inform our instruction and evaluation of emergency physicians, and call for our field to develop high-quality education research.

A systematic approach to education research in EM is essential for the continued improvement of clinical emergency care, even for providers beyond residency training.    In the decade since the Institute of Medicine's 2001 "Crossing the Quality Chasm" report identified the failure of health care environments to consistently deliver evidence-based care, the increased emphasis on translational research and patient safety has identified even broader needs for education-based research.  Without well-designed studies to investigate the most effective methods to teach and evaluate emergency physicians, scientific discoveries cannot be effectively disseminated to physicians in training or in practice, nor the benefits fully realized by our patients.

This Consensus Conference on Education Research in Emergency Medicine proposes to build a solid foundation upon which EM education researchers can build interdisciplinary scholarship, networks of expertise, discussion forums, multicenter collaborations, evidence-based publications and improved learner education.  Such efforts will enable us to make significant contributions to the state of knowledge in medical education and, ultimately, to optimize patient care.

Consensus Conference Goals:

• Provide an overview of the current state of education research in EM 
• Identify and examine the barriers that educators face in conducting well-powered, rigorous education research, and develop recommendations for overcoming these barriers
• Define most appropriate and effective methods for conducting education research studies
• Identify priority agenda areas within specific education research domains, such as:
• Establishing the effectiveness of clinical and didactic curricula in educating EM trainees in each of the six ACGME core competencies
• Evaluating performance of learners across the continuum of medical education, from medical student to practicing emergency physician
• Validating educational assessment tools
• Teaching and evaluating non-cognitive ACGME core competencies, such as “Professionalism” and “Interpersonal and Communication Skills”
• Measuring the impact of educational interventions to improve patient safety
• Research designs conducive to studying education outcomes
• Develop a framework to increase collaboration, access to research support and potential funding sources and promote faculty development in education research

Original contributions describing relevant research or concepts on this topic will be considered for publication in the December 2012 issue of Academic Emergency Medicine if received by Monday, March 12, 2012.  All submissions will undergo peer review and publication cannot be guaranteed.  For queries, please contact Nicole DeIorio, MD (deiorion@ohsu.edu), Joseph LaMantia, MD (JLaManti@nshs.edu), or Lalena Yarris, MD (yarrisl@ohsu.edu), Consensus Conference Co-chairs.  Information and updates will be regularly posted in Academic Emergency Medicine, the SAEM Newsletter, and the journal and SAEM websites.

Article review: Message for new generation of educators

An interesting article was published in Medical Education which you don't see too often in journals. It's a first-person reflective account of Dr. Ronald Harden's long and internationally well-regarded career in medical education. No p-value. No sample size calculation. His experiences and lessons learned provide great insight. Here's his advice to current and future educators.

1. People are important.

• Be a great clinician-educator role model for learners.

2. Innovation in medical education is complex.

• Beware of confounding factors and bias.

3. Nudges are important.

• Because medical education is a social discipline, be subtle in how you make changes. Small changes or recommendations play better than large, sweeping changes and top-down mandates.

4. Students are important as players.

• Today's students are different from students 10 years ago. Today's students are "digital natives." Personalized curricula will be important because every student has different needs.
• "It is important to have as the aim directed self-learning rather than self-directed learning." That means educators should provide some structural framework in how students conduct independent learning. 

5. Offer practical solutions to problems.

6. There is always something to learn outside one’s practice.

• Attend an education conference outside of your specialty. To make real progress in medical education, there needs to be better cross-collaboration.

7. Publish.

• "If I had to live my life again I would place greater priority on documenting what I did and publishing it."

8. Learn from history.

• Don't reinvent the wheel.

9. Obtain independent funding.

• Although it is very challenging to obtain external funding, it forces one to be clear and concise about why one's study is important and how it should be conducted.

10. Have fun! 


Reference

Harden RM. Looking back to the future: a message for a new generation of medical educators. Medical Education. 2011;45(8), 777-84 PMID: 21752074
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Paucis Verbis: Diagnostic testing tips for acute abdominal pain

In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.

My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead -- more accurate and less radiation.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Panebianco NL, Jahnes K, Mills AM. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin N Amer . 2011;29(2):175-93. PMID: 21515175
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Advice for the new EM interns

One of my favorite blogs, Better in Emergency Medicine, by Dr. Rob Cooney reviewed the 1991 article entitled "The Ten Commandments in Emergency Medicine". These commandments are timeless and still hold true today. Rob gives a helpful review of each commandment's relevance in today's ED.

1. Secure the ABC's
2. Consider or give naloxone, glucose, and thiamine
3. Get a pregnancy test
4. Assume the worst
5. Do not send unstable patients to radiology
6. Look for common red flags
7. Trust no one, believe nothing (not even yourself)
8. Learn from your mistakes
9. Do unto others as you would do to your family (and that includes coworkers)
10. When in doubt, always err on the side of the patient

Tricks of the Trade: Underwater ultrasonography

I've heard of underwater basketweaving, but underwater ultrasonography?

Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient's extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient's skin and transducer. What's a quicker and easier way to create some distance yet preserve image quality?

Trick of the Trade:
Submerse both the body part and the ultrasound transducer under water.

For this "bath water technique", start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.

Thanks to Andy at Emergency Medicine Ireland blog for these 2 ultrasound images! 

This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient's wound.

Reference
Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267
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TED-Ed Brain Trust: "Catalyzing an education revolution"

If you have not heard of TED videos, I highly encourage you to view them. They are short, inspirational, and professional talks by leaders, scientists, and artists, who focus on bringing together the 3 worlds of Technology, Entertainment, and Design.

Because many of these videos focus primarily on education, TED has just built a new online community of educators called the "TED-Ed Brain Trust". The mission is to bring together "the expertise of visionary educators, students, organizations, filmmakers and other creative professionals to guide, galvanize and ultimately lead this exciting new initiative."

Registration to join the Brain Trust is free and open to the public. Below is a Prezi presentation explaining the vision for TED-Ed. Click on the right arrow to view the presentation.

Article Review: Redesigning a Powerpoint lecture using multimedia design principles

Let's rethink how we design our Powerpoint slides. Let's create design principles using Mayer's cognitive theory of multimedia learning.

Cognitive Theory of Multimedia Learning
In a nutshell, people learn through two channels -- words and images. This dual-channel theory suggests that people process auditory and visual stimuli separately. Each channel requires time to process information before merge into a cohesive cognitive concept.

Dual Channel Theory for Multimedia Learning

(click to enlarge)

Based on this dual-channel theory, Mayer developed some key principles in designing multimedia materials. The key is to minimize cognitive load, or the burden on one's working memory during instruction. Some examples from the highlighted article include:

• Make the message stick: Simplify using images. Get the message across by making the header a sentence rather than a phrase. Avoid bullet points.

• Signaling principle. Highlight only the essential material.

• Coherence principle. Avoid distractors and eliminate unnecessary words, pictures, and sounds.

In a prospective study this month from Medical Education, traditional Powerpoint slides were compared to modified Powerpoint slides in a lecture on Shock. The content remained the same. The modified Powerpoint slides implemented Mayer's multimedia design principles. Many other principles are nicely summarized at Design eLearning blog. A convenience sample of Surgery clerkship third-year medical students were enrolled (n=39 traditional, n=91 modified).

Based on a pre-test/post-test design, the authors found that the students were able to recall facts better (eg. "Define shock.") using the "modified" Powerpoint slides. Interestingly, the "modified slides" students did not perform any better than the control group in their ability to transfer their knowledge in written clinical vignettes.

This was a great study. I hope they pursue this line of inquiry. More studies need to look at using multimedia effectively for teaching.

In the meantime, I am definitely going to be reading more about Mayer's work.

Reference
Issa N, Schuller M, Santacaterina S, Shapiro M, Wang E, Mayer RE, Darosa DA. Applying multimedia design principles enhances learning in medical education. Medical Education. 2011; 45(8), 818-26. PMID: 21752078
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Paucis Verbis: NSAIDS and upper GI bleeds

Primum non nocere. 

Do no harm.

We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?

Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don't have a history of a GI bleed or peptic ulcer.

You can download this PV card:  [MS Word] [PDF]
See other Paucis Verbis cards.

Reference
Massó González EL, Patrignani P, Tacconelli S, García Rodríguez LA. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis and Rheumatism. 2010;62(6), 1592-1601. PMID: 20178131
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Doing well as a new EM attending physician

You are super-excited to get your first real job as an emergency physician after residency. Then this immediately turns into a nauseating, super-terrified feeling, right?

After posting two entries [1, 2] to help medical students do well on their EM clerkship rotation, a commenter suggested that I provide a list of tips for doing well as a new EM attending physician. Although there is slightly variation for community versus academic faculty, many of the basic tenets hold true:

1. Be an accurate charter.
Let's face it. In the end, departments are driven by money. Don't let the department leadership think that they are losing money on you. So, if you do the bedside ultrasound, do a critical care resuscitation, or suture a simple laceration, chart it. It's good for billing, and it's good for medicolegal reasons. Documentation is key. I'm not saying to overbill but rather to be accurate in what you chart.

2. Be nice to the nurses.
This is the same advice I always give to students and residents on the EM rotation. Coming into a new practice environment is difficult by itself. The nurses can make it less... or more challenging. Take a minute to introduce yourself to those who you don't know. Be approachable. Keep them apprised of the patient's overall plan. Personally, I brought candy on my first shift, and that tradition has never quite gone away.

3. Get to know key players in and out of the ED.
Over time, get to know the consultants, radiologists, radiology technicians, custodial staff, and ancillary staff. This smooths-over many of the intangible hurdles that we encounter on a day to day basis in the ED.

4. Be a role model.
You now represent the face of the department for patients, nurses, consultants, and residents/students (if you have any). Don't be late. Be cognizant of where you voice informal comments. Someone impressionable is always listening.

5. Familiarize yourself with the resuscitation equipment before starting your first shift.
You may be the world's intubation expert, but if you can't figure out where the spare endotracheal tubes and laryngoscopes are, things go bad quickly.

6. Realize that you are working in a different ED.
Every Emergency Department has its little quirks. Nothing irritates people than someone new, who constantly reminds others that "When I was at _____, we did it this way." Try to figure out how your ED handles different scenarios. Examples at my hospital include:

• Patients with pancreatitis often get admitted to our Surgery service and not Internal Medicine. 
• On the weekdays, trauma airways are managed by an Anesthesia resident and not an EM resident.
• Our ED tends to prescribe only vicodin and percocet (and rarely oxycodone or darvocet). 

7. Decide on how you want to access clinical information.
You won't know the solution to every problem in the ED. There's something that surprises me every day. That's the upside and downside of EM. I admit that in my first year, I called my residency program's ED to "curbside" an attending once. Decide on how you want to be able to look up information. Will it be by using:

• PEPID?
• Epocrates/Micromedex mobile app?
• UpToDate?
• EMedicine.com?

8. Keep up to date with the literature.
It is all about lifelong learning. Learning does not stop after residency. Devise a plan to keep apprised of the major updates. This might include doing one or several of the following:

• Subscribing to a few journals. I personally read Annals of EM, Academic EM, and EM Clinics of North America. 
• Attend an occasional national meeting. 
• Subscribe to various podcasts, videocasts, or online websites such as EM-RAP, CME Download, or Emedhome.com, respectively. [Disclosure: I am not affiliated with any of these products.]
• If you are a community emergency physician, attend a few EM residency conferences in your area. I'm sure they'd appreciate your insight from a non-academic site perspective.

Any other suggestions that you can think of?

Trick of the Trade: Anesthetizing the nasal tract

One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness.

Trick of the Trade:
Targeted approach using viscous lidocaine on Q-tips

Put copious amounts of viscous lidocaine on the cotton end of a long Q-tip. Slide the Q-tip into the nose along the NG tube or NP scope tract. When you feel the end of the swab reach resistance and/or the patient has discomfort, stop advancing the Q-tip. Twirl it to spread the lidocaine. Leave it there for a few seconds until they can't feel the Q-tip anymore. Then advance and repeat until you get to the back of the nasopharynx. You may need to reload the Q-tip with more lidocaine. This technique applies lidocaine to the most sensitive areas while also testing for anesthetic effectiveness.

You can supplement this technique with nebulized lidocaine to anesthetize the posterior oropharynx to minimize the gag reflex.

Thanks to Dr. Adrian Flores (UCSF-SFGH EM resident) for this great idea! 

Emergency Medicine factoids on Twitter

The medical profession is slowly incorporating Twitter. If you have a Twitter account, here are some great Twitter accounts to follow:

@EM_PEARLS

• Written by Dr. Brian Kloss (EM faculty at SUNY Upstate Medical University)
• EM nuggets of wisdom, targeted for medical students, EM residents, and mid-level practitioners

@EMEducation

• Written by Dr. Rob Cooney (EM faculty at Conemaugh University) and of Better in Emergency Medicine blog fame.  
• Written in a question-answer format, this account provides great pearls targeted for EM residents.

@CDEMUpdates

• I created this account a few years ago but never really did anything with this. The CDEM (Clerkship Directors in EM) organization is now more formally organizing our social media team.
• Written by a team of CDEM faculty, this account targets medical students on their EM clerkship rotation. 

Any other Twitter account suggestions?

New website for medical education researchers

There is a great new website "Medical Education Subject Guide", hosted by UCSF's own Josephine Tan, tailored to medical education research and academic scholarship. I've been a long-time admirer of Josephine's work as an Education and Information Consultant in Clinical Sciences for the UCSF Library.

This compiles and lists helpful resources, which include books, journals, databases, multimedia resources, organizations, literature search tips, and blogs. The site also links to her two blogs:

Medical Education Literature Searching

• Literature searching tips and educational insights

In Plain Sight

• This blog provides information searching and citation management tips,  as well as educational insights to enhance the faculty, researcher, clinician, and student information seeking, management, presentation, and publication experience.

Wish I had these resources when I became interested in medical education and education research...

Paucis Verbis: Cardiac tamponade or just an effusion?

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it's relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it's equivocal? How good is the clinical exam and EKG in ruling out a tamponade?

Answer: Poor to average, at best. The Beck's triad of hypotension, distended neck veins, and muffled heart sounds are important to remember ... only on tests.

Solution: Think about performing a pulsus paradoxus test to see if it's >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Take a look at this helpful video demonstrating how to measure pulsus paradoxus.

Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!

Reference
Roy C et al. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA: The Journal of the American Medical Association. 2007; 297(16): 1810-8. DOI: 10.1001/jama.297.16.1810
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Joining the Facebook age

With the recent "awesome" news about Facebook teaming up with Skype for video chatting yesterday, I thought it was time for the blog to also join the Facebook world. Thanks to Dr. Hans Rosenberg for pushing me to do this.

I finally created Academic Life in Emergency Medicine's Facebook Page. I think that it works. By clicking on the Facebook "Like" icon in the right column of this blog, your Facebook stream should import each blog post automatically. Suggestions for improvement on the Facebook Page are welcome.

Building the page was a rather user-UNfriendly process. Briefly, here are the steps if you are interested in building your own Facebook Page.

1. After creating a Facebook Page, click on Edit Page button in the upper right.

2. From the left column, select "Apps". One of the apps is "Notes". Click on "Go to App" under Notes.

3. In the bottom left column, click on "Edit Import Settings". This will then ask you to enter the URL of the blog that you want to import.

Trick of the Trade: Epistaxis control with tongue blades

For epistaxis, the classic teaching is to pinch the nose to control the bleeding. A persistent nosebleed often is the result of one's natural inclination to constantly check if there is still bleeding every few seconds. Applying pressure on-and-off makes it difficult for the bleeding to stop.

Trick of the Trade:
Use tongue blades to pinch the nose.

Don't rely on the patient to apply constant pressure to the nose. It is too tempting to intermittently check for bleeding. Instead create a "nose pincher" by taping the end of two tongue blades together (at the level of the green arrow). Wedge the nose between the open ends. Leave the tongue blades in place for at least 20 minutes.

The photo is courtesy of my friend Dr. Matthew Lewin.

A faculty's perspective: Doing well on your EM clerkship

To follow-up with Dr. Connolly's post about the Top 10 tips for medical students to rock the EM clerkship rotation, I thought I would post some additional tips. Here are some more pearls:

11. Take ownership of your patients. 
This means that you should take it upon yourself to make sure that your patient's care is stellar, addresses key clinical and social issues, and is timely. Constantly check for your patient's results. Don't be the last to hear of your patient's lab or imaging results. Figure out why there are unexpected delays. Address any psychosocial issues which may hamper your patient's clinical improvement in the ED.

12. Have a learning plan on shift.
It's helpful to yourself and others to have a focused learning plan for each shift. For instance, this might be -- I want to get better at reading plain films. Let the senior resident and attending know. This fulfills two purposes. First, you'll likely get pulled in to view and read films even though they might not involve your patient. Usually the senior resident or attending will keep a lookout for interesting findings. Second, this shows that you are an active learner who is seeking out learning opportunities rather than letting them passively and randomly occur.

13. Don't be late to your shift.
'Nuff said.

14. In addition to trauma shears, carry a very bright pen light. 
A bright light source comes in handy all the time. I use a bright LED pen light and I constantly use it on shift. This works well especially when trying to examine for laceration, foreign bodies, and other such injuries.

15. Befriend the nurses.
This is a good general rule of thumb for everyone. The nurses are a key part of the medical team and have great clinical gestalt about what is going on with the patients. Introduce yourself to them at the start of your shift. Listen seriously to their concerns and comments. They are a wealth of wisdom and can help answer many of your questions.

16. Clean up your sharps and equipment after procedures.
This is a corollary to rule #15.

17. Start learning about bedside ultrasonography.
This bedside tool is constantly being used in the Emergency Department an. Read up a little on the more common types of ultrasound exams. The most common are probably vascular ultrasounds for central line access and the FAST exam. If you can, try to get some hands-on experience on your cases. Hey, maybe your learning plan for one of your shifts might be to become more adept at bedside ultrasonography!

Good luck to the new MS4 medical students!

Happy 4th of July

Be safe and PLEASE stay out of the Emergency Department.

Paucis Verbis: Blunt cerebrovascular injuries

In the setting of blunt trauma, it is easily to overlook a patient's risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke.

• Who are at risk for these injuries? 
• What kind of imaging should I order to rule these injuries out? 
• Do I really treat these patients with antithrombotic agents even in the setting of trauma to reduce the incidence of CVA?

FYI: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit probably need imaging.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Burlew CC, Biffl WL. Imaging for blunt carotid and vertebral artery injuries. Surgical Clinics of North America. 2011, 91(1), 217-31. PMID: 21184911
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