Vacation: No post today

Self-imposed, vacation day. 

I'm declaring today as one of many national "Wellness" days. Have a great weekend.

Sorry for the no-post. 

Keep a look out for Dr. Stella Yiu's upcoming poll regarding a student's behavior: "What you do if YOU were on the residency selection committee?"

Join.Me: A free online screenshare and phone conferencing tool

Skype, FaceTime, Google+ Hangout.

So many options!

I recently used a free online tool at Join.Me so that 3 people can discuss the statistical analysis of a paper we are working on. But it's so hard to get 3 busy people in the same room at the same time! So, we tried Join.Me. We basically needed to view one shared computer to review the statistical data and share a conference call phone line.

What I was immediately impressed by was the simplicity in the whole process. It's FREE and PC-/Mac-compatible.

1. Go to the simplistically appealing home page (see above).
2. Click on the orange"share" icon.
3. This automatically downloads a software package which you should install.
4. Open the Join.Me software app on your computer.

5. A pop-up screen (above) will appear. Now click on the Share icon.

6. This will automatically give you an URL link to share with others to view your screen PLUS a free conference call line.

Here's a sample promotional image of what a session looks like:

We had a great meeting about a multicenter (11 hospitals!) educational study on the impact of an English-based pediatric software on physician decision making in Vietnam. It was super-fast, efficient, and hassle-free.





  

Trick of the Trade: Needlestick hotline 888-448-4911

You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient's venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It's difficult to concentrate when faced with so many questions whirling in your mind.

Trick of the Trade:
Use the National Clinicians' Post Exposure Prophylaxis (PEP) Hotline - 1-888-448-4911

"The PEPline provides around-the-clock expert guidance in managing healthcare worker exposures to HIV and hepatitis B and C. Callers receive immediate post-exposure prophylaxis recommendations.  Available 24/7."

Remember this is for providers who are exposed and not the lay public.

I was not only surprised to find that this national hotline is hosted by UCSF/SFGH (my home institution!) but also helmed by my friend Dr. Goldschmidt (Professor and Vice Chair, Department of Family and Community Medicine).

For more information about the National HIV/AIDS Clinicians' Consultation Corner, which staffs the PEPline, view their website at: http://www.nccc.ucsf.edu/about_nccc/pepline/

On the website, they also feature a "Warmline" at 800-933-3413, which is staffed by physicians, clinical pharmacists and nurse practitioners Mondays through Fridays, from 5 am to 5 pm (Pacific Time). They provide up-to-date information for the care of your HIV-positive patient.

Paucis Verbis: Does this DM leg ulcer have osteomyelitis?

We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it's the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you'll be surprised by what you find.

Several questions come up with diabetic foot ulcers:

• Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer?
• Is there underlying osteomyelitis?
• How can I best diagnostically work this foot ulcer up for osteomyelitis?
• What is the Wagner grade of this ulcer? (I think it'd be Grade 2.) 

Thanks to JAMA's Clinical Rational Examination series, there is a systematic review of diabetic leg ulcers and osteomyelitis. Here are the highlights:

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

See other Paucis Verbis cards.

Below is the Bayes nomogram to help you plot out your post-test probability based on your likelihood ratios. The example given is if your pretest probability is 25% and your LR is 10. Your post-test probability would be 80%.

Reference

Butalia S et al. Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity? JAMA. 2008; 299(7), 806-13. DOI: 10.1001/jama.299.7.806.
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Get feedback on your PPT or PDF files: Reelapp.com

www.ReelApp.com

The smart folks at Zurb have come up with a clever app. This free Web-based app, called Reel, allows you to quickly collect thumbs-up/ thumbs-down votes on each slide or image. . Think of it as Slideshare with a "likes" feature added.

So if you are working on a Powerpoint, a series of images, or even PDF's and want feedback from friends and colleagues without having to email the large file around, think about uploading to Reel. What a great way of crowd-sourcing feedback.

For instance, here are my "Tricks of the Trade" lectures slides for the upcoming ACEP meeting in October. See how you can give a like or hate vote to each slide. Feedback is welcome but alas they already made me turn in the files a long while ago.




Note: This only works for still images, so movie files in my Powerpoint slides don't work.

Trick of the Trade: Pediatric ear exam

Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:

• Balloonimals iPhone app to grossly assess peak flow
• Candleflame iPhone app to grossly assess peak flow
• Eye Handbook iPhone app with pediatric fixation animation targets
• Casting/splinting your buddy bear

What's your trick on performing an otoscope exam of the ears?




Trick of the Trade:
The case of the disappearing otoscope "hat"

A slight of hand can easily make the otoscope speculum disappear. Your apparent search for this missing "hat" can make it easier for you to examine the ears.


Thanks to Dr. Chris Nickson (Life in the Fast Lane) for the find!

Paucis Verbis: Legionella pneumonia

Did you know that there was an unexplained spike in Legionnaire's disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic?

Since the flu season is rapidly approaching, I thought I would review what Legionnaire's disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip.

Why do we want to differentiate it from other pneumonias?
Legionnaire's disease requires reporting to your state's health department to help track for outbreaks.

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

See other Paucis Verbis cards.

More information on Legionellosis from the CDC website.

Reference
Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010 Mar;24(1):73-105. PMID: 20171547
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Trick of the Trade: Synovial lactate in septic arthritis

A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. "It feels different than my RA flare."

Does this patient have a septic joint?

The difficulty in diagnosing this elusive disease is that the history, physical, and serum tests are typically unhelpful in ruling in or out the disease. See my previous Paucis Verbis card covering the 2007 JAMA review on Septic Arthritis.

Interpretation of the synovial fluid is also challenging. Generally a synovial WBC count <25K suggests a non-infectious process and a WBC count >100K suggests an infectious process.

What about everything in between 25K and 100K?

Trick of the Trade:
Check if the synovial lactate level is > 10 mmol/L.

A level >10 mmol/L is highly suggestive of septic arthritis. The calculated positive likelihood ratio (LR) from multiple studies was at least 10. The negative LR ranged from  0 to 0.45.

Although the quoted studies measured lactate using liquid chromatography, presumably our point-of-care lactate levels are equivalent, based on various sepsis studies.

How do you use the LR statistic? I'm no statistician, and so I love the Bayes nomogram. This requires me to have a pretest probability for the disease. In this case, let's say that I am moderately suspicious of a septic joint given the patient's history of rheumatoid arthritis (a known risk factor), significant joint pain, and low grade fever. I'm going to say that my pretest probability is 25% (see left column of numbers).

The synovial lactate level returns at 12 mmol/L (see middle column of numbers), which gives the patient a positive LR of at least 10.

This means that my post-test probability for a septic joint jumps way up to 80%, which practically rules-in my patient for septic joint.

Reference
Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based Diagnostics: Adult Septic Arthritis. Acad Emerg Med. 2011;18(8), 781-96. PMID: 21843213
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Poll: YOU are the clerkship director - What would YOU do?

You are teaching a clerkship seminar and a student kept checking her iPhone for Facebook updates. You reminded her that she probably should not be distracted and she replied, "Well, I don't need to know ACLS. I am applying to Dermatology anyways."

You happen to be meeting the Dermatology Program Director later that day...

Please feel free to type in your comments below to explain your answer.

Paucis Verbis: Distracting injuries in c-spine injuries

"Distracting injury" is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of "distracting injury". Although both are studies at different sites, both conclude the same:

• Chest injuries may be considered "distracting injuries" because of their proximity to the cervical spine.  

So let's say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a "long bone fracture"), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might consider this patient to have a "distracting injury" because of the long bone fracture. Instead, the literature now supports your clinically clearing the cervical spine without imaging.

Wait, let's rethink this. Does this mean that you should get cervical spine imaging for ALL blunt trauma patients with ANY chest wall tenderness?! NO. That's just crazy. You should still factor in the mechanism of injury, severity of pain, and your clinical gestalt.

So for me, these "distracting injury" studies are helpful such that:

• If your trauma patient does NOT have chest trauma, it may help you avoid unnecessary cervical spine imaging, as suggested by the NEXUS criteria.
• If your trauma patient DOES have significant chest trauma, I have a lower threshold to obtain cervical spine imaging despite the neck being non-tender.

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

See other Paucis Verbis cards.

Brief survey: Need your help with my promotions!

With all of the advances in technology and social media, the "old school" world of traditional academia doesn't know what to do with medical professionals who incorporate technologies into their educational practices. To justify these past 2 years of blogging during my free time, I wanted to collect data on who my readers are and the impact of my blog (if any).

I could sure use a few minutes of your time and input to help with my promotions process. Let's push traditional academia to change with the times. Thanks a bunch.

UPDATE (9/9/11): Wow, I am overwhelmed and humbled by everyone's kind words. This survey alone illustrates the power, reach, and immediacy of social media. I've gotten 147 responses already! (see responses on Google Docs Forms). Now I know for certain that I am on the right track in pushing for social media technologies in medical education. 



This is the first time I have used Google Docs Forms to build a survey. Pretty cool.

Trick of the Trade: Epley maneuver

You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.

Is your first-line treatment meclizine or benzodiazepines?






Trick of the Trade:
Epley maneuver (Canalith Repositioning Procedure)

Although the 2004 Cochrane review states that the Epley maneuver is of questionable benefit, a 2010 systematic review demonstrated that there is a significant benefit from Epley maneuver. The trick is remembering all of the steps correctly.

• The first position is really the Dix-Hallpike maneuver in the direction (right vs left) which causes more vertigo or nystagmus.
• Wait 30-60 seconds.
• While remaining supine with the head extended 25-30 degrees, rotate the head 90 degrees until it is facing the other shoulder.
• Wait 30-60 seconds.
• Have the patient cross his/her knees and arms.
• Have the patient roll onto his/her side (same side as looking towards) while keeping the head facing the shoulder. This positions the face so that it is almost now facing the floor. If done correctly, this should exacerbate the vertigo because the canaliths are repositioning themselves.   
• Wait 30-60 seconds. 
• Assist the patient in sittting up by swinging their legs off the edge of the table and sitting up "like a windshield wiper".
• Lastly, have the patient look downward around 30 degrees.

You can recommend that your patient look at YouTube videos at home to help remind them of the steps that they can do at home every night.

Reference
Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010 May;90(5):663-78.

Paucis Verbis: Antibiotics for Cystitis & Pyelonephritis in Women

You diagnose a 35 years old woman with uncomplicated cystitis. She is not diabetic and not pregnant. Which antibiotics should you give? What if she had pyelonephritis?

Answer: It depends on your local antibiogram.

Today, go find out about your hospital's local resistance rates for uropathogens to various antibiotics. For San Francisco General Hospital, I found our 2010 antibiogram publicly posted online. Urine isolates of E. coli demonstrate relatively high resistance rates to trimethoprim-sulfamethoxazole and ciprofloxacin:

• Trimethoprim-sulfamethoxazole resistance rate = 33%
• Cefazolin or Cephalexin resistance rate = 12%
• Ciprofloxacin resistance rate = 16%

So based on the new 2010 practice guidelines by the ID Society of America and the European Society for Microbiology and Infectious Diseases, I should give:

• Cystitis: Nitrofurantoin x 5 days, or cephalexin / beta-lactam x 3-7 days
• Pyelonephritis: Ceftriaxone 1 gm IV x 1 + (ciprofloxacin x 7 days or trimethoprim-sulfamethoxazole x 14 days)

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

See other Paucis Verbis cards.

Reference
Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE, Infectious Diseases Society of America, & European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases. 2011; 52(5). PMID: 21292654
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