Holiday break: Dec 23-31

Happy holidays!

Accuracy	True to literature
Valid for practice	Overall quality

Physical exams: A relic of the past?

Why do most of us dread patients who complain of dizziness in the ED? Because it is so vague, and the differential is so broad from elusive posterior cerebellar strokes to ear wax clogging up our ear canals. And this is one of those diagnoses where the differential really depends upon performing a thorough physical examination.

Think really hard, when is the last time you focused upon getting a complete and accurate physical examination? In medical school, there are courses dedicated to the art. I always laugh when I think of my neurology attending who just loved to bang on different parts of the body with his reflex hammer to elicit cool reflexes.

Then comes the real world!  Sure, we can see a waiting room full of patients on a busy day. But this is without writing a single note, not taking a bathroom break, and barely talking to consults. What, I wonder, could possibly be the accuracy of my physical exam findings during those days? Could we be missing important findings by skipping time consuming things such as pelvic exams?

We push so hard to be efficient, but what is the impact? Think of how often we probably inappropriately work up patients because we don’t take the time to do good exams. A great example: really deciphering right upper quadrant pain so that a patient gets an ultrasound to rule out cholecystitis versus quickly palpating the abdomen while taking a history and just going for an abdominal CT scan in order to find “something”.

Worst of all, we model this type of behavior for the medical students and junior residents who work with us. When is the last time you actually went back and reviewed the physical exam findings with your presenter? When they told you that the patient was tachypneic, did you go back to the bedside, lift up the shirt and count the breaths together? 

But to do so requires a firm understanding of physical exam findings for yourself.

Here are my thoughts:

1. Examine all of your patients thoroughly, focusing upon the pertinent systems for their diagnosis.  Get them undressed!
2. Try to make time to watch consult services perform their physical exams. For example neurology specializes in the neuro exam. They have a lot to potentially teach us.
3. Review exam findings with medical students and junior residents which will improve your own skills.
4. Open up a physical exam book. I used Bates Guide to Physical Examination and History Taking in medical school. There is no shame on opening it up now. For musculoskeletal examinations, The Orthopaedic Physical Exam by Bruce Reider is a must.
5. Realize the extreme importance of physical exams! It is not as sexy as ultrasounding an optic nerve sheath diameter, but it is absolutely vital to our role as physicians.

Top 7 people I follow on Twitter (outside of EM)

Only in the past two years did I begin to follow Twitter accounts of those outside of the specialty of emergency medicine. Now I can't imagine not belonging to this broader community. More often than I not, I realize that others have the same "what if?" and "why not?" thoughts like me when it comes to the intersection between technologies, education theories, and medical education.

I often get asked who I follow on Twitter outside of EM. Here are some of my favorites:

My short talk on story, imagery, & 21st-century presentation delivered at TEDxKyoto 2012 now on line: tinyurl.com/8dbwxe7
— Garr Reynolds (@presentationzen) October 20, 2012

1. PresentationZen (Japan)

• Garr Reynolds
• Speaker, blogger, designer on a journey... 
• Blog: http://www.presentationzen.com
• The author of the Presentation Zen book series on how to be a better presenter and avoid the perils of slide design
• Number of Twitter followers: 21,802 

Authentic Presentations Take Practice - 6th post in this @harvardbiz series! Check them all out here: ow.ly/fIpHT
— Nancy Duarte (@nancyduarte) December 1, 2012

2. NancyDuarte (Mountain View, CA)

• Nancy Duarte
• CEO and author. Passionate about persuasion and visual stories used in business. Love hugs from hubby, 3 kids and grandoggies
• Blog: www.duarte.com/
• Author of Resonate and all-around innovative thinking about design and presentation 
• Number of Twitter followers: 22,510
  

The Taxonomy of Social Media via @edsocialmedia ow.ly/g89Ot
— nancyrubin (@nancyrubin) December 15, 2012

3. NancyRubin (New York, NY)

• Nancy Rubin
• Interdisciplinary Ph.D, twitterholic, compulsive sharer about social media and learning
• Collates and curates from a multitude of education sources
• Blog: nancy-rubin.com/
• Number of followers: 6,468

33 charts: Would Sal Khan Survive in Academic Medicine? bit.ly/YvY8ym #AAMC12 #MedEd
— Bryan Vartabedian (@Doctor_V) November 5, 2012

4. Doctor_V (Woodlands, TX)

• Bryan Vartebedian, MD
• Dispatches from the frontline of social media and medicine #tweetiatrician
• A pediatric gastroenterologist who blogs at www.33charts.com
• Number of followers: 11,274
  

Trauma Mythbusters: NSAIDs And Fracture Healing tmblr.co/ZdXARyYeccB1
— Regions Trauma (@RegionsTrauma) December 4, 2012

5. RegionsTrauma (St Paul, MN)

• Michael McGonigal MD
• Director of the Trauma Service at Regions Hospital who provides great insight and tips from the perspective of a trauma surgeon
• Blog: regionstraumapro.com
• Number of followers: 1,011
  

Chart Review: A New Carnival for Academic Medicine Blogs soc.li/YoKvGu
— Wing Of Zock (@wingofzock) December 4, 2012

6. WingOfZock (Washington DC)

• The Twitter account for the Association for American Medical Colleges 
• A blog for conversation and new thinking about health care through the lens of academic medicine.
• A great account to follow for an insight into academic medicine, specifically with regards to undergraduate medical education
• http://wingofzock.org
• Number of followers: 1,010
  

Keynote Isaacson: In #meded smart people are a dime a dozen. What you need are innovators. #aamc12
— Katherine Chretien(@MotherinMed) November 5, 2012

7. MothersInMed (Washington DC)

• Internist, medical educator, humor writer, founder/editor of Mothers in Medicine group blog. On Board of Contributors at USA TODAY.
• The author of the landmark JAMA article on professionalism and social media
• Blog: www.mothersinmedicine.com
• Number of followers: 3,259

Who would you recommend?

Trick of the Trade: Combine Adenosine with the Flush

The success of adenosine depends as much on the administration technique as it does the mechanism of action. The 2010 Advanced Cardiac Life Support (ACLS) Guidelines recommend the following when administering adenosine:

"6 mg IV as a rapid IV push followed by a 20 mL saline flush; repeat if required as 12 mg IV push"

While most drugs are metabolized in the liver, adenosine doesn't even make it that far, being metabolized in the erythrocytes and vascular endothelial cells. With this extremely short half-life (10 seconds), it is important to help it reach the heart before it's metabolized and excreted without being effective.

There are a variety of methods to administer adenosine. Some will push it through a running IV line, followed by two 10-mL saline flushes.

Others will utilize a stopcock, where the adenosine is hooked up to one port and a 10-mL saline flush is hooked up to the other. After the adenosine is pushed, the swivel is switched and the 10-mL saline flush quickly follows.

Others, still, will use a hybrid of these two methods. The problem with all of these approaches is that it takes time to switch syringes. Even if utilizing the stopcock, nurse unfamiliarity with how to maneuver the port from OFF to ON may lead to some fumbling. With almost any other drug, a few seconds lost here or there wouldn't matter. But it can with adenosine.

Trick of the Trade: Combine the adenosine and flush solution in one syringe.

• Grab a 20-mL (or 30-mL) syringe.
• Draw up the adenosine AND the normal saline in the same 20-mL syringe.
• Administer via fast IV push (can be through a running IV line).

The major advantage to this approach is that it obviates the need for any syringe switching or stopcock swiveling. There's no need for additional flushes since your diluted adenosine syringe doubles as the flush. If you don't have 20-mL syringes, you can still add the adenosine to one of the two 10-mL saline flushes to get the same effect. Flush volumes as low as 5 mL have been effective [4].

Adenosine is stable in, and compatible with, normal saline [2, 3]. Even if you're giving a 12 mg dose, the adenosine will only take up 4 mL of volume, leaving 16 mL for the normal saline. A small study from Korea demonstrated the feasibility and effectiveness of this approach compared to the standard techniques [7]. The efficacy of diluted adenosine was also demonstrated in a study by Lopez-Palop et al., albeit by the intracoronary route [6].

Read more about when to consider alternative doses of adenosine from my previous post.

Original: December 18, 2012
Last updated: January 18, 2013

References

1. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 Suppl 3):S729-67. [PMID 20956224]
2. Ketkar VA, Kolling WM, Nardviriyakul N, et al. Stability of undiluted and diluted adenosine at three temperatures in syringes and bags. Am J Health Syst Pharm 1998;55(5):466-70. [PMID 9522931]
3. Kaltenbach M, Hutchinson DJ, Bollinger JE, et al. Stability of diluted adenosine in polyvinyl chloride infusion bags. Am J Health Syst Pharm 2011;68(16):1533-6. [PMID 21817085]
4. Gausche M, Persse DE, Sugarman T, Shea SR, Palmer GL, Lewis RJ, Brueske PJ, Mahadevan S, Melio FR, Kuwate JH, et al. Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia. Ann Emerg Med 1994;24(2):183-9. [PMID 8037382]
5. Ng GA, Martin W, Rankin AC. Imaging of adenosine bolus transit following intravenous administration: insights into antiarrhythmic efficacy. Heart 1999;82(2):163-9. PubMed [PMID: 10409529] PDF
6. Lopez-Palop R, Saura D, Pinar E, et al. Adequate intracoronary adenosine doses to achieve maximum hyperaemia in coronary functional studies by pressure derived fractional flow reserve: a dose response study. Heart 2004;90(1):95-6. [PMID 14676256]
7. Choi SC, Yoon SK, Kim GW, et al. A convenient method of adenosine administration for paroxysmal supraventricular tachycardia. J Korean Soc Emerg Med 2003;14(3):224-7.

Tweet Pearls of the Week 12/7 to 12/14

Because a good tweet is a terrible thing to waste!

Better viewed on a laptop or desktop on fullscreen

Hypotensive a fib, and does calcium before diltiazem work? #FOAMed... tmblr.co/ZgnhMvZBFesd
— EM Res (@BobStuntz) December 12, 2012

@bobstuntz @pharmertoxguy @amalmattu Ca++ sounds reasonable - have also used @emcrit 's push-dose phenylephrine in unstable afib, as well.
— Ryan Radecki (@emlitofnote) December 12, 2012

Love it when I diagnose an achilles tendon rupture by #ultrasound and the ortho doc requests I review the images with him to learn...
— Laleh Gharahbaghian (@SonoSpot) December 11, 2012

CT demonstrating the internal anatomy of a zucchini and the abdomen in a patient with rectal perforation! #Radiology twitter.com/RadiologySigns…
— Radiology Signs (@RadiologySigns) December 9, 2012

Twitter is the digital watercooler in Medicine

I just don't have time to join Twitter.

Are you serious, Twitter?

Being in the minority of medical providers who use Twitter for work, these are common responses I hear. I would make the counter argument that it has given me opportunities to learn, collaborate, and share on a much more efficient level. 

The best argument that I can come up with is that it is the new digital, global watercooler in Medicine. The difference from your current watercooler area is that this area includes global thought-leaders and educators. Seriously, who wouldn't want to eavesdrop on conversations and learn from leaders like Amal Mattu, Scott Weingart, and Mike Cadogan?

• It's where we hear of interesting new studies or controversial clinical tips. 
• It's where we bounce ideas off each other so that we go off and learn more on our own. 
• It's where we see practice variations worldwide.

Question to the collective: 

What has been your best argument for why one should join Twitter? 

Here's my recent "Digital Watercooler" article in Emergency Physicians Monthly. This will launch a new EP Monthly column capturing Twitter conversations, written by our very own Dr. Javier Benítez! Keep a lookout for it.

Patwari Academy videos: ACLS and post-resuscitation care

This is the last installment of Dr. Rahul Patwari's digital whiteboard video talks on ACLS, specifically focusing on post-resuscitation care and therapeutic hypothermia.

• Parts 1-3 (ACLS and airway)
• Parts 4-6 (ACLS: cardiac arrest)
• Parts 7-10 (ACLS: bradycardias and tachycardias)

To debrief or not?

Learners have limited time. Residents have work hours restrictions, practicing physicians have work / life demands, and the list goes on. Time is valuable. Therefore, educational interventions must be hard-hitting, effective, and worthwhile.

We discussed previously "What is debriefing?" Debriefing is a facilitated discussion and reflection about objectives previously chosen by the educator. Dr. Ernest Wang (NorthShore Center for Simulation and Innovation) states that it's about getting learners to that “aha!” moment.

NCSI CSTAR Facilitative Debriefing Video from Ernest Wang on Vimeo.

According to Fanning and Gaba [1], deciding when to debrief is twofold:

1. Do participants lack a sense of closure? 
2. Can we derive useful insights through a discussion of the experience? 

Therefore, we debrief to give participants a conclusion to their learning experience, a manner by which to derive conclusions. We also debrief to provide insights as a group that may not be possible to derive as individuals.

Dr. Roger Greenaway is a UK PhD who specializes in training organizations on the benefits of active and experiential learning.  His website has published a list of 10 reasons on why to review (aka debrief).  These are some of the important points:

• Getting unstuck: Debriefing helps the learner to progress in the cycle of learning and development. 
• Opening new perspectives: Learners can understand complexities in medical management and realize that there is more than one right answer. 
• Developing observational awareness: We all want to become thoughtful and observant physicians able to gather subtle patient clues and condense medical information quickly. Debriefing helps to point out missed clues.

Think of debriefing as a way of accelerating knowledge acquisition and takes learners to the next level. So it is definitely hard hitting!

This is the second of several blog posts on debriefing. Future write ups will discuss the evidence behind debriefing, debriefing techniques, and where to get formal training in debriefing.

References

1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007. Summer;2(2):115-25. PMID 19088616.
2. Thiagarajan S: Using games for debriefing. Simul Gaming 1992;23: 161–173.

PV card: Metacarpal fractures

What do these two patients with metacarpal fractures have in common?

Answer:

These patients have injuries which need reduction in the ED.

• Patient #1: Rotation deformities of the fingers, while held in flexion should be reduced. All fingers should normally point towards the patient's scaphoid bone.
• Patient #2: Fractures of the base of the 4th and 5th MCs often are associated with carpometacarpal (CMC) dislocations. This 4th MC fracture-CMC dislocation should definitely be reduced.  

Metacarpal (MC) fractures are common injuries, which often spark discussions about whether they should be reduced in the ED urgently.

• What are the criteria for acceptable degrees of angulation? Are these criteria different for the MC neck versus shaft? 
• Which fractures tend to be unstable and thus require eventual operative repair? 
• How should I splint the injury?

Here's a quick-reference card to help guide your management decisions. These recommendations may vary slightly based on what references you use. You may need to tailor your decisions based on your regional practices.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Nicole Strauss at the UCSF-SFGH Orthopaedic Trauma Institute and my go-to hand expert for her input.

Additional reference
Friedrich JB, Vedder NB. An evidence-based approach to metacarpal fractures. Plast Reconstr Surg. 2010 Dec;126(6):2205-9.

Trick of the Trade: Speed up ECG paper rate to differentiate tachycardias

Undifferentiated tachycardias, especially when the rate is extremely fast, make it difficult to see anything other than the QRS complexes! Is there a P or flutter wave?

Trick of the Trade:
Double the ECG paper speed to 50 mm/sec

Standard ECG machines run at 25 mm/sec. If you double the paper output speed, subtle ECG findings hidden in the tracings become more evident. Imagine the ECG tracing as a string and that you are pulling on both ends. Everything, including the QRS complex and intervals, gets wider.

What are your experiences with this?

Atrial flutter at 150 bpm:

• Standard rate 25 mm/sec 

• Faster rate 50 mm/sec (red arrows are flutter waves)

Thanks to Dr. Amal Mattu for sharing his ECGs with me from his University of Maryland ECG archives. If you haven't heard of this amazing ECG video series, you should definitely check it out.

Below is the video teaching this point within the topic of narrow-complex regular tachycardias. This trick is seen at the 15:00 minute mark.

For another example, check out Dr. John Larkin's blog ECG of the Week post on a pediatric SVT rhythm at 300 bpm with no P waves seen at 50 mm/sec.


Reference
Accardi AJ, Miller R, Holmes JF. Enhanced diagnosis of narrow complex tachycardias with increased electrocardiograph speed. J Emerg Med. 2002 Feb;22(2):123-6. Pubmed .

Gaspar JL, Body R. Best evidence topic report. Differential diagnosis of narrow complex tachycardias by increasing electrocardiograph speed. Emerg Med J. 2005 Oct;22(10):730-2. Pubmed Free PDF

Tweet Pearls of the Week 11/30 to 12/7

Because a good tweet is a terrible thing to waste!

Better viewed with desktop or laptop on full screen. 

Patwari Academy videos: ACLS (parts 7-10)

What is the definition of bradycardia and tachycardia in the 2010 ACLS guidelines, for the purposes of resuscitation algorithms?

• Bradycardia: heart rate < 50 bpm
• Tachycardia: heart rate > 150 bpm

Below are the next 3 video installments of Dr. Rahul Patwari's digital whiteboard talks on ACLS. These videos cover both bradycardias and tachycardias.

Teaching internationally: More than just a language barrier

I recently traveled to San Salvador to help teach a pediatric and adult ultrasound course. The course was well received and it was wonderful traveling around San Salvador.

I wanted to share some of our experiences, and discuss some challenges to educating internationally. More importantly, I want to engage you, the readers to share some of your experiences when educating internationally as well.

The language

The first challenge and major road block was attempting to lecture in a foreign language. Although I studied Spanish for many years, I was definitely rusty. While I learned the history of the Argentinian Dirty War in school, I never mastered vocabulary sufficient to discuss the physics of ultrasound. We translated the majority of the presentations into Spanish by using the aid of colleagues who were from El Salvador and Google translator. Imagine how difficult this would be for languages that are not based on the Roman alphabet or if there were no native language speaking colleagues to assist. Even with that, there were still some funny hiccups.

Delivering presentations

Creating the presentations is half the battle. Delivering the presentation is even more daunting.

We all know that good lecturers don’t read off of their slides.  They can ad-lib, interact with the crowd, and make adjustments as necessary.  This becomes more difficult in another language.  No one wants to deliver a bad presentation simply because it is in another language.  Or worse, give a bizarre answer to a question because of translation issues.  I definitely practiced my presentations more than I would usually.  The butterflies in my belly before presenting were palpable!

AV equipment

A major challenge was ensuring that the AV equipment worked properly.  Although traveling with 5 other EM physicians in my group, none of us remembered to bring a dongle to connect our laptops with the AV equipment in the hospital.  Luckily, we were able to find a store and could buy the necessary missing equipment.  However, you may not always be so lucky when traveling internationally to be near an urban center.  It is important to be organized to try to limit as much AV malfunction as possible.  Remain flexible and know that there may be some level of malfunction and be prepared to address it.  Having a backup plan such as hard copies of the lecture could be life (and reputation) saving.

Ultrasound equipment

Finally there is the challenge of traveling with the portable ultrasounds internationally.

• Customs doesn’t always know what a portable ultrasound machine is. Plus, it takes coordination to organize carry-on luggage as the ultrasound, check in your suitcase, and manage your souvenirs-- all without incurring additional travels charges.
• Don’t forget how heavy the ultrasound machines can be on your back!  
• Ultrasound machines are expensive. We always knew their locations to avoid losing them.

Ethical question
There was the ethical dilemma of using our high tech portable ultrasound donated by companies for international education versus using the machines that the hospitals already had.  Our equipment was definitely more advanced, but what purpose does it serve to not teach familiarity to what is available?  This is a thought that definitely can be pondered upon and argued over.

Lessons I learned:

•  Practice, practice, and practice again when delivering a presentation that is not in your primary language
•   Think about AV equipment - consider backups
•   Ultrasound machines are heavy and costly
•   Always consider sustainability

Please share any lessons you may have learned while traveling and educating internationally!

Is the 6-12-12 adenosine approach always correct?

The ACLS-recommended dosing strategy of 6 mg, 12 mg, and 12 mg for adenosine may not be appropriate in every situation. There are a few instances when lower or higher dosing should be considered.

Caveat: All recommendations are data-based, but many factors affect successful conversion of paroxysmal supraventricular tachycardia (PSVT) including proper line placement and administration technique.


Option 1: Starting at higher dose

Caffeine is an adenosine blocker and can interfere with the successful reversion of PSVT. In fact, ingestion of caffeine less than 4 hours before a 6-mg adenosine bolus significantly reduced its effectiveness in the treatment of PSVT. An increased initial adenosine dose may be indicated for these patients.

Remember that theophylline may require higher dosing as well, because it is similar to caffeine (another methylxanthine), but is not prescribed much in the U.S. anymore.

Recommended dosing strategy [1]:

• 1st dose: 12 mg (instead of 6)
• 2nd/3rd doses: 18 mg (instead of 12)

Option 2: Starting at lower dose
Every so often a patient arrives in PSVT with their only IV access being through a hemodialysis port. The initial adenosine dose should be reduced if administered through a central line. Remember a central line delivers the adenosine right where you need it. This recommendation is supported by the 2010 ACLS guidelines. Cases of prolonged bradycardia and severe side effects have been reported after full-dose adenosine through a central line.

Also consider lower doses in patients concomitantly taking carbamazepine or dipyridamole or in those with a transplanted heart.

Recommended dosing strategy [2, 3, 4]:

• 1st dose: 3 mg (instead of 6)
• 2nd/3rd doses: 6 mg (instead of 12)

References

1. Cabalag MS, et al. Recent caffeine ingestion reduces adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia. Acad Emerg Med 2009;17(1):44-9. [PMID 20003123]
2. Chang M, et al. Adenosine dose should be less when administered through a central line. J Emerg Med 2002;22(2):195-8. [PMID 11858927]
3. Neumar RW, et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S729-S767. [PMID 20956256]
4. McIntosh-Yellin NL, et al. Safety and efficacy of central intravenous bolus administration for termination of supraventricular tachycardia. J Am Coll Cardiol 1993;22:741-5. [PMID 8354807]

Poll: How would manage a metacarpal fracture in the ED?

I am in the process of creating a PV card on metacarpal fractures, divided into anatomical areas (base, shaft, neck, head), and am realizing that the EM and orthopedic literature don't quite agree. Actually they are quite vague on whether reductions should occur in the ED vs orthopedics clinic in the next few days.

• Do you need to close-reduce all angulated fractures in the ED, which are outside of "acceptable" angulations?
• What exactly are "acceptable" angulations? Some sources say that angulations of 10, 20, 30, and 40 degrees are acceptable for MC neck fractures and only 10, 10, 20, and 20 degrees are acceptable for MC shaft fractures. These numbers, though, vary from reference to reference.

The only consistent thing I've read is that rotational angulation (where not all the fingers point to the patient's scaphoid bone) requires reduction in the ED because of the concern for functional impairment.

School of thought #1:
Reduce all angulated fractures. Heck, it's bent. Straighten it.

School of thought #2: 
Leave all fractures alone. As many of 50% of fractures, especially unstable ones, will lose their realigned position when the patient is seen at the outpatient orthopedic visit. Just splint it and follow-up.

School of thought #3: 
I reduce some but not all angulated fractures.

Would love to hear the variations in people's practice. Feel free to use the Comments section of the blog to explain.

Trick of the Trade: Ultrasound-guided supraclavicular central line

Subclavian central lines are commonly touted as the central line site least prone to infection and thrombosis. The problem is that they are traditionally performed without ultrasound guidance. They are done blindly because of the transducer's difficulty in getting a good view with the clavicle in the way.

Trick of the Trade:
Ultrasound-guided supraclavicular approach to subclavian line

What are the surface anatomy landmarks for the supraclavicular line?

• Identify the border of the clavicle and lateral margin of the clavicular belly of the sternocleidomastoid muscle. 
• Insert the needle there and aim for the contralateral nipple, aiming anteriorly 10-20 degrees to avoid puncturing the subclavian artery and lung.
• You are trying to cannulate the near the juncture of the IJ and subclavian veins. 

If you just want to see the crux of the procedure, which uses the linear transducer to guide the long-axis needle insertion approach, start at 8:18.

Disclaimer: I do not have any commercial affiliations with Sonosite.

Reference
Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: the forgotten central line. West J Emerg Med. 2009 May;10(2):110-4. Free access to PDF

Tweet Pearls of the Week 11/23 to 11/30

Because a good is a terrible thing to waste!

Better viewed on a desktop or laptop using full screen. 

Patwari Academy videos: ACLS (parts 4-6)

Below are the next 3 video installments of Dr. Rahul Patwari's digital whiteboard talks on ACLS. These videos cover:

• Cardiac arrest (Vfib and Vtach)
• Cardiac arrest (More of Vfib and Vtach)
• Cardiac arrest (Asystole and PEA)

I love that each video is less than 15 minutes long. Also, even if you aren't a medical student, these are great refreshers. For instance, don't forget that atropine is no longer on the 2010 ACLS algorithm for asystole.