Trick of the Trade: Rare earth magnets for metallic FB removal

A child presents to your Emergency Department with a small button battery up her nose. Your usual tricks fail:

• Occluding the other nostril and having the mother blow in the patient's mouth forcefully.
• Using a small curette or forceps to scoop or pull it out.

Trick of the Trade:
Use a Rare Earth Magnet

This YouTube video (apparently, you CAN find anything on YouTube) shows an amazing demonstration of how simple foreign body removal can be. It seems to be much less traumatic than if one were to actually go digging into the cornea for the little metallic bits.

One of the conference attendees our recent High Risk EM Conference in Hawaii came up to tell me of his success in using rare earth magnets for metallic foreign body removals in the nose, ears, and even deep lacerations. I wish I had caught his name to give him credit! Cool tip.

I recently bought some Rare Earth Magnets from eBay for $8. I bought a set of 20 mini-magnets which can be stacked together into a wand. Here is a video showing how strong these little magnets are in picking up random things in my house:

I do not have any financial ties or disclosures with eBay or the sellers of these cool rare-earth magnets.

Video: Crash course on Prezi

Dr. Rob Rogers has started a great series of videos which highlight resources and tools which medical educators may find useful and innovative. This video takes you on a guided tour through making a Prezi presentation. Although I am still torn about using Prezi as a delivery tool because of the excessive motion-based transitions, I do like such features as:

• Really professional looking templates
• The presentations can live online and/or on your desktop
• Ability to easily embed videos 
• Ability to see your entire presentation on the canvas
• Allows more flexibility in content delivery
• It just looks cool.

You can look for more excellent videos on the Academic Emergency Medicine Education Masters site. Hey maybe you can next teach people how to use Google Reader, Evernote, Dropbox!

Paucis Verbis: Anaphylaxis

Image from WebMD

Anaphylaxis is one of the most under-appreciated and under-treated conditions in the Emergency Department. A common misperception is that you need hypotension to diagnose it. Below is a brief summary of the diagnostic criteria and ED treatment protocol. Immediate administration of IM epinephrine is critical.

A major challenge is deciding which patients can go home and which need to be admitted, because of the risk of "rebound" or a biphasic anaphylactic response. This may occur as late as 72 hours later, but typically occur within the first 24 hours. There isn't a good answer for this.

What's your practice in dispositioning these patients? Personally, I admit at least those patients who present with severe hypotension, require more than 1 epinephrine dose, or have poor social support.

NOTE: Unlike the photo on the top, warn patients not to rest their thumb on the device because of the risk inadvertent needle puncture.

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

See other Paucis Verbis cards.

Reference

Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S161-81. .

Arnold JJ, Williams PM. Anaphylaxis: recognition and management. Am Fam Physician. 2011 Nov 15;84(10):1111-8. .

On vacation

Had an exciting week making new friends and learning about hot topics in Emergency Medicine at our department's UCSF High Risk Emergency Medicine Hawaii conference.

Will be back next Friday!

Live-blogging: UCSF High Risk EM Hawaii conference

Today is the pre-day for our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. Keep a lookout below as I try to live-blog some of the clinical pearls that I glean from the day (using Google Docs).

Live blogging tomorrow

Tomorrow is the beginning of our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. I'm going to try to live-blog some of the clinical pearls that I glean from the day.

Article review: New assessment method for medical students - A Script Concordance Test

What different ways can we assess learners?

This fascinating study assesses a new tool - Script Concordance Test (SCT).

Assessing clinical reasoning skills in scenarios of uncertainty: Convergent validity for a Script Concordance Test in an Emergency Medicine clerkship and residency

What are Scripts?

Scripts are organized networks of knowledge. Integrating them improves decision making. Using scripts, experts see associations while novices struggle with causality. In ambiguous cases, experts process multiple scripts with influx of new information.

What is the format of a Script Concordance Test?

The learners are presented with a short clinical vignette with a series of proposed diagnoses and/or plans. The learners are then presented one new piece of information and asked what effect this information has on the proposed diagnoses and/or plans. They score their decisions on a Likert scale, ranging from -2 to +2.

What did this paper study?

An observational study comparing the scores of 4th year med students (n=314) , residents (n=40) and faculty (n=12) on a SCT with scenarios in Emergency Medicine. The student score was compared to USMLE Step 2 score, and resident score with their ABEM in-training exam score.

What were the results?

The SCT scores were able to differentiate students from residents and residents from faculty. 

• Students vs residents: 60% +/- 6.2 vs 70% +/- 5.4
• Residents vs faculty: 70% +/- 5.4 vs 79% +/- 2.9

There was a significant correlation between resident score and ABEM exam score and a modest correlation between student score and USMLE Step 2 score.

What were the limitations?

It is a single centre study. The internal reliability of the assessment tool was suboptimal.

What were the conclusions?

The SCT may be useful in assessing clinical reasoning in uncertain scenarios.

What do I think?

I enjoy the examples given in the paper. While it is different and likely will take some getting used to, it could be a useful assessment tool.

References

Humbert AJ, Besinger B, Miech EJ. Assessing clinical reasoning skills in scenarios of uncertainty: convergent validity for a Script Concordance Test in an emergency medicine clerkship and residency. Acad Emerg Med. 2011;18(6):627-34. .

Paucis Verbis: Pediatric fever without a source (3 mo-3 yr)

In part 3 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants 3 months to 3 years old (PV cards for birth-28 days and 29 days-3 months old).

Notes:

• The algorithm below is a guideline for NON-toxic patients. More ill-appearing children require a more broad workup.
• For the under-immunized (<2 PCV immunizations) and temperature ≥39.5C, blood cultures may be falling out of favor in the near future, because the incidence of blood culture contaminants is close to exceeding the true incidence of occult bacteremia.

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

See other Paucis Verbis cards.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

Blog incubation project: New 2 winners!

And the winners of the first ever EM Blog Incubator competition are...

Dr. Jim Campagna (Emergency physician at St Joseph's Hospital Health Center in Syracuse, NY) and Dr. Timothy Peck (Beth Israel Deaconess EM resident in Boston, MA)

Both submitted really fascinating concepts for their blogs. I'm really looking forward to reading each of their 3-part introductory series in the upcoming weeks, as they prepare to launch their own blogs.

Dr. Jim Campagna

Jim plans to focus on the all-things-technology in Emergency Medicine. This includes reviewing and aggregating lists of medical apps and hardware which are relevant to the specialty. Furthermore, he will provide up-to-date literature reviews of other technologies, such as electronic medical records and computer physician order entry, and their impact on clinical practice.

Dr. Timothy Peck

Tim isn't a newcomer to the blogging world. He has a fantastic blog "Teach, MD: Rethinking medical education" since July 2011. On his new blog, Web 2.0 Changed My Management, will feature examples of how Web 2.0 influenced the management of specific patient encounters. Also guests will be allowed to contribute mini-case presentations where they will report how a Web 2.0 activity changed how they managed a patient.

I can't wait to see what Jim and Tim come up with!

Paucis Verbis: Fever without a source (29 days-3 months old)

In part 2 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants aged 29 days to 3 months (PV card for birth-28 days). Note that there is no single correct answer in how to manage these patients. There can be a wide variation in practices, partly because of the slightly different criteria used by the 3 studies. The overarching principle is that "high risk" infants get admitted with IV ceftriaxone and "low risk" infants get discharged with close follow-up +/- a ceftriaxone IV or IM dose. The line between these two risk categories is the grey area.

Where I practice, we tend to follow a modified version of the Rochester criteria, where a lumbar puncture and antibiotics aren't always required for this age group (unlike the Boston criteria).

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

See other Paucis Verbis cards.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.