TED video: The happy secret to better work

If you have a few minutes, take a listen to this rather humorous and thought-provoking TED video about the "intersection of human potential, success, and happiness". The speaker, Shawn Achor, is the CEO of Good Think Inc, a Cambridge-based consulting firm which researches positive outliers -- people who are well above average, and author of "The Happiness Advantage".

Quote:
“If we study what is merely average, we will remain merely average.”

Resuscitation 2012 conference

What are you doing the rest of this week? Hop on a plane to Las Vegas and join me at the 2012 Resuscitation conference. It looks to be a great conference.

http://www.resuscitation-conference.com/schedule.htm

I'll be giving a 3-hour (!) discussion session on "Tips and Tricks in Emergency Medicine" on Friday. Inevitably when I given this talk, I always come away with great ideas from the audience. I'll be sure to write them down and share on the blog.

Trick of the Trade: Protecting your thumbs in mandible relocations

From Emedicine.com

Does anyone think that this is generally a bad idea when closed-reducing mandible dislocations? Yes, it's easiest to apply downward pressure on the mandible by pushing down on the occlusal surfaces of the molar teeth. Sometimes, however, when the mandible relocates into place, the teeth clamp shut abruptly - placing your thumbs at risk. How can you prevent any injuries to yourself?


One way is to slide gauze into the mouth during your procedure. Start the video around the 1:30 mark for an exam.

Trick of the Trade:
Apply a protective roll of gauze over each thumb. Additionally, you can wear a second glove to cover the gauze. No, those are NOT just fat thumbs under the gloves.

Thanks to Dr. Liz Brown (UCSF-SFGH EM resident) for the trick!

Paucis Verbis: Blunt Abdominal Injury, Likelihood Ratios

This month's issue of JAMA addresses the question "Does this patient have a blunt intra-abdominal injury?" as part of the always-popular Rational Clinical Examination series.

The systematic review of the literature summarizes the accuracy of findings for your blunt trauma patient in diagnosing intra-abdominal injuries. Specifically, likelihood ratios (LR) are summarized. These LRs can be used to plot on the Bayes nomogram below. You draw a straight line connecting your pretest probability and the LR. This yields your posttest probability.

The most predictive positive LR include: Abdominal rebound tenderness, a "seat belt sign", ED hypotension, hematocrit < 30%, AST or ALT > 130, urine with > 25 RBCs, base deficit < -6 mEq/L, and a positive FAST ultrasound. 

The trouble is that the absence of these findings aren't as helpful in ruling-out injury, with negative LR's very close to 1.0. The two exceptions are base deficit and FAST ultrasound with a negative LR of 0.12 and 0.26, respectively.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

I find it interesting that there are studies on hepatic transaminase levels. Anyone else getting these in their trauma patients? I traditionally don't. Many of our patients have a history of hepatitis C and underlying alcoholic hepatitis. If suspicious for blunt abdominal trauma, we just get the CT.

Also, the article attempted to figure out a constellation of findings which would effectively rule-out intra-abdominal injuries. Since none of these are validated, I didn't include them on this card.

Reference
Nishijima NK et al. JAMA. 2012;307(14):1517-1527. .

Trick of the Trade: Peritonsillar abscess aspiration technique

Photo courtesy of Dr. Hagop Afarian (Fresno)

A few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the great, creative ideas that came up during our discussion.

An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter.   I can never find syringes with the side rings to allow you to grasp the syringe more securely with one hand (see photo above).

Trick of the Trade:
Have an assistant apply negative pressure to a syringe connected to the needle using IV tubing

Build a kit similar to the butterfly phlebotomy setup (above drawing).

• Attach IV extension tubing to the spinal needle. 
• Attach the other end of the IV tubing to the syringe. 
• Ask the assistant to apply negative pressure on the syringe once you have penetrated the oral mucosal surface.
• Now you can focus on just directing the needle to the appropriate area.

If you don't have an assistant, you can also rig a vacutainer hub to the end of the extension tubing, again similar to a phlebotomy set up. Just imagine the same setup as below except with a spinal needle at the end instead of a butterfly needle.

Thanks to Dr. Nick Kanaan (Stanford-Kaiser EM co-chief resident) for telling me about his trick.

Paucis Verbis: GRACE score for ACS risk stratification

Risk stratification of the undifferentiated chest pain patients in the Emergency Department continues to  plague emergency physicians. It's partly the reason why I created a TIMI risk score card for unstable angina and non-ST elevation MI in 2010.

Have you heard of the 9-variable GRACE risk stratification score? Thanks to Jeff Bray (physician assistant in a rural critical access ED), I have now. He graciously shared his personal reference card on this with me, which I only minimally reformatted to fit my Paucis Verbis card dimensions.

GRACE stands for Global Registry for Acute Coronary Events. It supposedly outperforms the TIMI scoring slightly in accurately predicting complications in the short and long term. Instead of calculating this manually, which can be a pain, now there are calculators out there:

• GRACE website calculator
• MD Calc website
• Mediquation mobile app (per Jeff)

Anyone use this scoring system?

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference

1. Eagle KA, et al; GRACE Investigators. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA. 2004 Jun 9;291(22):2727-33. Pubmed .
2. D'Ascenzo F, et al. TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: A meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients. Contemp Clin Trials. 2012 May;33(3):507-14. Pubmed  .

Dr. Rob Rogers' new Tumblr site

The ever-prolific Dr. Rob Rogers (Univ of Maryland) is hosting all of his Medical Education Videos on his new Tumbler website:

http://mededumem.tumblr.com/

Thus far he has videos on:

• Camtasia screencapturing
• Khan Academy
• Prezi
• Life in the Fastlane blog

Keep up the great work!

Video: How to make a screencast video

A reader, Mark, posted a question yesterday in the chat box about screencapture softwares out there. I personally use iShowU to capture such videos as my instructional video on linking your Evernote account (above) to automatically read and download my weekly public Paucis Verbis notebook. Mark also specifically asked about what Dr. Rob Rogers (Univ of Maryland) uses.

Like magic, Rob made us a special 5-minute video to explain how he uses Camtasia for his screencapture videos.

I have no affiliation with iShowU or Camtasia. Like Rob mentions in his video, I'll be working until I'm 95 years old as well because I have no affiliations...

Trick of the Trade: Urine pregnancy test without urine

A 25 year old woman presents to the Emergency Department having syncopized in the waiting room, where she was triaged with the chief complaint of abdominal pain. Ectopic pregnancy immediately bubbles to the top of your differential diagnosis.

The patient is too dizzy to walk to the bathroom to give you a urine specimen to check a urine pregnancy test. Plus, she admits that she just urinated in the waiting room bathroom a few minutes ago - so no urine now.

Trick of the Trade
Apply several drops of whole blood (instead of urine) into the pregnancy test casette

Did you know that most urine pregnancy test kits are approved for both urine and serum samples? On a quick Google search, I found that Accutest, ICON, OSOM, and Rapid Response all are approved for both. The question is whether this will work for whole blood.

One study (1) in the Journal of Emergency Medicine by Dr. Fromm from Maimonides Medical Center looked at exactly this issue. Whole blood pregnancy test performed extremely well, especially if positive:

• Sensitivity 95.8%
• Specificity 100%
• Negative predictive value 97.9%
• Positive predictive value 100%

In their study, very low beta-HCG values (<159 mIU/mL) occasionally yielded a false negative for whole blood pregnancy tests. It missed 9 of 425 pregnancies. 

Bottom line: Believe a positive test. Confirm with a urine test or quantitative beta-HCG. 

Tip: Be sure to wait at least 5 minutes when using whole blood in the kit. It sometimes takes a while. See the photos, courtesy of Dr. Joe Habboushe (New York Hospital–Queens of Cornell University) and Dr. Graham Walker (Stanford). 

Time = 1 minute

Time = 5 minutes

S = Sample well
T = Test specific (will show bar if +HCG)
C = Control (will always have a bar)

Reference

1. Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting Whole Blood for Urine in a Bedside Pregnancy Test. J Emerg Med. 2011 Aug 27. Pubmed .
2. Habbousche JP, Walker G. Novel use of a urine pregnancy test using whole blood. Am J Emerg Med. 2011 Sep;29(7):840.e3-4. Pubmed .

Modern EM: Case #4 - Palpitations



Caution: this caterpillar has been known to cause sudden cardiac death



Case # 4: Palpitations

A 25 year old woman presents with palpitations, sweating, and shortness of breath since this morning. 6 days ago she had syncopized, was shocked out of V-tach by EMS, and eventually had a defibrillator placed for an unknown arrhythmia. Now, she feels her heart beating in her chest, looks diaphoretic, is tachypnic, but her pulse is 58 and regular.

Resources used:

• G+
• Dr. Smith's EKG Blog
• Academic Life in Emergency Medicine

I looked on the monitor and she was beating away at about 60 bpm and it looked normal sinus rhythm. An EKG showed this:

Join me on G+.  I edited the grainy picture I took on my phone to what you see above in 2 minutes

The EKG was normal sinus rhythm and looked entirely normal except for this odd pattern in V2 (and somewhat in V1). Could it be a saddle-back? Is this Brugada syndrome?

I opened the Paucis Verbis card about Brugada by Michelle Lin on Academic Life in EM on my iPad and saw this:

I called the electrophysiologist, and I sent the EKG to his phone. I told him that I thought she had Brugada syndrome, and he told me it was something close, but not quite - because in V2 the J-point is not > 2mm. The patient would be fine because she already had the AICD placed. Some ativan, reassurance, and encouragment to call her insurance company to inquire about her outpatient mental health benefits fixed the problem. You'd be anxious too if you literally died earlier that week.

I went home after the shift and opened Dr. Smith's EKG Blog, searched Brugada and learned that the pattern could be unmasked by common occurances like fever, cocaine, propofol, and lidocaine. "Get this patient some Tylenol. We need to break his fever, STAT" I imagined myself saying next time I had a saddle-back with fever.

Brugada has a high incidence of sudden cardiac death. Although this was not a true Brugada, this patient who had an EKG that sure looked a lot like Brugada had suffered from sudden cardiac death. I'll leave the specific rules of diagnosing Brugada to the cardiologists - the saddleback is my can't miss diagnosis.

This is a guest series by Dr. Timothy Peck, who is launching his own blog at ModernEM.blogspot.com. Check it out!