Survey: Why do you use Twitter?

I recently got a comment on the blog asking why people need to use Twitter, if they're already following blogs. I thought I would open this up to the blogosphere.

I personally use my Twitter account (@M_Lin) for a variety of reasons:

• I tweet the link to my blog whenever there is a new post (I just tweeted a link to this post!)
• Scan quick, real-time information from clinicians I trust
• Know "what's hot" in EM, medical education, and education technologies
• Learn of new blogs and websites which I didn't know about
• Quickly check tweets on-the-fly on my iPhone during downtimes
• Make new friends who I then meet in person at EM conferences!

Please comment below and include your Twitter name, if possible.  I'd love to know why (or why you don't) use Twitter.

Trick of the Trade: Mark your sites with a Sharpie

Marking the surface anatomy for procedures can significantly increase your chances for success, such as for lumbar punctures and central lines. I can never seem to find surgical skin markers.

Trick of the Trade:
Use a Sharpie marker

Did you know that Sharpies are inherently sterile, likely because they contain N-propanol? There was an in vitro study where they used a Sharpie vs Secureline (surgical skin marker) to draw across blood agar plates inoculated with various bacteria. At 4 hours, there was no bacterial growth on the Sharpie pen tip, while all of the Securelines had bacterial growth.

Read more: http://www.jstor.org/stable/10.1086/650377

Thanks to Dr. Jeff Wiswell (PGY-2 EM resident and upcoming chief resident at Mayo) for this tip! He recently recounted his use of a sharpie:

I recently had a patient arrive with massive angioedema who was metastable but needed a definitive airway.  As we were administering glycopyrrolate and nebulized/topicalized lidocaine, along with getting our fiberoptics setup, I was thinking about my backup plans.

We had a glidescope, LMA, and crich kit at the bedside, but the thing that gave me the most confidence was the Sharpie marker I realized was in my scrub top.

After reading a study about their superior sterility compared to disposable surgical pens, I've been using them to mark landmarks for LPs and the IJ trajectory for needle placement on some central lines.

This evening, however, I directed the nurses to shave the lower half of this patient's beard and marked the cricothyroid membrane in a controlled setting before my fiberoptic attempt, knowing that I could ultimately locate it accurately and quickly if I reached the end of the algorithm.

Although the nasal fiberoptic attempt went beautifully, I'm not sure what the ICU residents upstairs noticed first:

1. The massive tongue protruding from the patient's mouth,
2. The nasal ETT, or
3. The big, blue "+" over the patient's neck . . .

Twitter conference notes: High Risk EM and Gaming Symposium

Yesterday, I attended two fantastic conferences and so wasn't able to make a new Paucis Verbis card:

• UCSF High Risk Emergency Medicine
• UCSF Gaming and Learning Symposium

Here are my Twitter notes for the day for those of you who don't use Twitter (and why don't you?!):

Trick of the Trade: Ear foreign body

Bead in external ear canal

From privatehealth.co.uk

Sometimes classic techniques need to be revisited, especially when I get new photos from the collective readership. Let's review a painless way to remove beads from the ear canal. You can't exactly have the patient's provider blow in the other ear to expulse the bead, similar to a nasal foreign body...

Trick of the Trade (revisisted):
Remove non-organic foreign bodies from the ear using a tissue adhesive

Back in 2010, I discussed how a few drops of a tissue adhesive on the end of wooden Q-tip stick can be used to attach to the foreign body. After waiting 20-30 seconds to let the glue dry, gently pull out the foreign body.

Dr. Edward Lew (PGY-2 EM resident from Cook County) recently shared with me his success story in a bead extraction. Instead of a Q-tip stick, he used a plastic ear pick with the tip cut off to provide a flat surface for the tissue adhesive. Nice job!

Paucis Verbis: Upper GI bleeding, part 2

Do you know what the Blatchford clinical prediction score is for upper GI bleeding? It can help you predict whether a patient with an upper GI bleed is severe and requires urgent intervention.

Hot off the presses, JAMA just came out with a great Clinical Rational Examination article on this topic. Thanks to Dr. Ryan Radecki (EMLitOfNote) for the heads up. The likelihood ratios and Blatchford risk stratification score are so useful that I'm breaking my PV rule to keep things down to the size of one index card. Note the absence of a NG lavage result to help you risk stratify for an upper GI bleed requiring urgent intervention using the Blanchard score.

Let's say you have a patient with a Blanchard score of 0, as in the case of the JAMA example. Starting with a general 30% pretest probability that your upper GI bleed patient has a severe GI bleed, your post-test probability becomes <1% for a severe GI bleed.

These are pages 2 and 3 of my Upper GI Bleed PV card (June 2011), which was originally based on an EM Clinics of North America review article. View page 1.

Bayes nomogram

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012 Mar 14;307(10):1072-9. Pubmed .

Moving Paucis Verbis in shared Dropbox folder to a public folder

The shared Dropbox folder option for my Paucis Verbis cards has been a bit quirky over the past years. Because the folder is a true "shared" folder, everyone has read and write capabilities. So, occasionally some of you have been renaming files, adding files, and even removing files without knowing that this is reflected in all 75 members' Dropbox folders.

So I decided to move to the Public folder option for Dropbox:

https://www.dropbox.com/sh/d4daseofgc9qmht/7MQ2K9vNw9

When you click on this link while logged into your Dropbox account from your desktop/laptop, you can select the option to add the folder to your Dropbox account. This is a READ-ONLY link. From now on, I won't be updating the previously shared Dropbox folder.

Personally, I like the Evernote option better. You can join my public Evernote folder with the added benefit of being able to search for terms on each card. For instance, if you search "pediatric", several cards will pop up including cards on pediatric head trauma, pediatric fevers stratified by age, and croup.

KidsCareEverywhere-Vietnam study findings: SAEM 2012 meeting

I recently had the pleasure of presenting our KidsCareEverywhere-Vietnam team's study findings at the national SAEM meeting in Chicago.

Bottom line: 
Despite knowing English as a second language, Vietnamese physicians were able to easily navigate an English-based, clinical decision support software (PEMSoft) after only a brief 80-minute training session, conducted by non-physicians. Their post-test exam scores improved by 84%!

Trick of the Trade: Stabilizing mandibular relocations

From GotoAID.com

Three weeks ago, I talked about more safely reducing mandibular dislocations. After successful completion of the procedure, how do you make sure that the patient doesn't re-dislocate the mandible? You definitely should tell the patient to keep their jaw closed as much as possible for the next 24 hours and avoid opening the mouth widely (eg. yawning/laughing).

How do you immobilize the mandible? Especially for the chronic dislocators, presumably with more lax TMJ ligaments, you should think about immobilization. This can be done with a head bandage which goes under the chin. You can use kerlix rolls or an ACE wrap.

Despite your best bandaging efforts, what can you do if your discharged patient returns from the ED parking lot with a recurrent dislocation?

Trick of the Trade:
Apply a semi-rigid cervical collar

Instead of "pulling up" the chin to stabilize the TMJ, a semi-rigid cervical spine collar can be used to "push up" the chin instead. This photo shows an Aspen collar, but you can use any of the semi-rigid collars you have available.

SAEM 2012 meeting and social media

Those of us active in social media had quite an active meeting at the Society for Academic Emergency Medicine meeting in Chicago, IL this past week.

First off, Dr. David Marcus (@EMIMDoc) from Long Island Jewish Medical Center, NY gave many of us blogs a kind shout-out.

Also, many "iReporters" were on scene to live-tweet various events. Take a look at some of the posts below. Click on #SAEM12 hashtag to see the whole Twitter feed. I remember hearing that there were over 600 tweets!

SAEM meeting: May 9-12, 2012 in Chicago

What are you doing this week? Are you at the annual SAEM meeting in Chicago? Stop by and say hi. There is an impressive list of abstract presentations for the meeting. I'll be giving an oral presentation on research data from KidCareEverywhere:

"An English-based pediatric emergency medicine software improves physician test performance: A multicenter study in Vietnam"

All I get is 5 minutes. By the time I read the title, I'll only have 4 minutes left!

Trick of the Trade: Bend the IV angiocatheter

You identify a great external jugular (EJ) vein to cannulate for IV access. You are having a hard time keeping the angle of the angiocatheter aimed at a shallow angle because the mandible is in the way. This is typical of patients with chubby necks (eg. pediatric patients) or who are unable to rotate their neck.




Trick of the Trade:
Bend the angle of the angiocatheter

Bend the proximal 1/3 portion of the needle slightly about 10-15 degrees. This allows you to approach the EJ vein at a shallow angle without hitting the mandible. Once you get a flashback of blood, feed the catheter as you normally would.

Tip: Don't bend right at the hub because it partly obstructs your ability to feed the cathether.

Thanks for Dr. Catilin Bilotti (UCSF-SFGH chief resident) for the video and tip!

Area of Distinction resident project: Health disparities and ED closures in California

Here is another slide set from our residency program's Area of Distinction presentation day.


Dr. Hemal Kanzaria presented his project on Health Disparities in California, specifically focusing on ED closures. The data was pulled from various state and national datasets. Of the 7.2% (29 of 401) of ED closures in California during 1998-2008, it seems that for-profit hospitals with a high proportion of non-White and MediCal patients are more at risk. Fascinating data.

Areas of Distinction resident project: Injuries in Golden Gate parks

Last week, I had the pleasure of listening to our graduating EM residents' Area of Distinction (AOD) project presentations. I was actually quite blown away be the caliber, sophistication, and variety of projects. I thought I'd share a few on the blog.

Here is the first one by Dr. Jake Miss on "Injury patterns and incidence in the Golden Gate National Recreation Area (GGNRA) during 2005-2009" his Wilderness Medicine AOD.

I am still wondering what a "foreign body" injury is from Table 2. Apparently there were two instances of this during the study period.

UCSF-SFGH Emergency Medicine residency program

Paucis Verbis: Genital Ulcers

A few months ago, American Family Physician published a nice review article on the diagnosis and management of genital ulcers. How do you remember the classic appearances of the lesions? I often quickly check references to confirm my suspicions.

I find the two following tables helpful to remember. The table of differential diagnoses is from AFP. The article also reviews the confirmatory diagnostic testing and treatment protocols. The table of the clinical characteristics for the main infectious causes is from "The Practitioner’s Handbook for the Management of Sexually Transmitted Disease".

Note: Although the primary lesion from Lymphogranuloma venereum (LGV) can have a variable appearance the tender, and often suppurative lymphadenopathy (buboes) are classic.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Images from "The Practitioner’s Handbook for the Management of Sexually Transmitted Disease", sponsored by the CDC (4th edition, 2007) can be found here:
http://depts.washington.edu/nnptc/online_training/std_handbook/gallery/index.html

Most recent 2010 CDC treatment guidelines:
http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm

Reference
Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012; 85(3):254-262. .

Trick of the Trade: Seldinger chest tube technique using bougie

A 40 year-old man presents with a traumatic hemopneumothorax. He weighs 400 pounds.

Chest tubes can sometimes be challenge, especially for those with extra redundant tissue to tunnel through before reaching the intrathoracic cavity. You want to avoid placing the chest tube mistakenly in the subcutaneous space. How can you ensure that your chest tube actually reaches the intrathoracic space?

Trick of the Trade:
Use a bougie as a "stylet" to guide your chest tube

Insert the thinner, longer, and semi-rigid bougie into the intrathoracic cavity. Confirm placement with your finger. Then slide the chest tube over it and remove the bougie. So elegantly simple and effective.

Images courtesy of Dr. Graham Walker (Kaiser San Francisco)

Thanks to the Twitter collective and Dr. Seth Trueger (@MDaware) for the tip! I believe the credit goes to Dr. Charles Maddow (UT Houston). Check out this Twitter thread and how this discussion came about. Another illustrative example of the power of social media.

Also see: Befriend the bougie from Life in the Fastlane