PV card: VBG versus ABG

Accuracy
Valid for practice
True to literature
Overall quality

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You obtain a venous blood gas (VBG) on a patient with a COPD exacerbation because you are concerned about hypercarbia. You get a value of 55 mmHg. How correlative is that compared to an arterial blood gas (ABG).

There has been a lot of literature on how well the pH correlates between the ABG and VBG but what about pCO2?

A small study (n=89) published in American Journal of Emergency Medicine in 2012 found that with a cutoff of pCO2 < 45 mmHg, the venous pCO2 is 100% sensitive in ruling out arterial hypercarbia. When the pCO2 was ≥ 45 mmHg, the VBG was less correlative.

Below is a review by Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob Bryant (Intermountain Medical Center in Utah) of the VBG vs ABG correlative data, along with a proposed algorithm on what to do with patients with COPD exacerbation.

What is your practice with an elevated pCO2 value on VBG?

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

[MS Word] [PDF v2]

See other Paucis Verbis cards.

Updated 1/31/13 at 2 pm PST:

• Changed range of pH correlation between VBG and ABG = 0.03-0.04
• Was typo in abstract of Kelly et al article [2]. View free BMJ Online full-text here. Stated difference between pHs was 0.4, rather than 0.04 as described in main results text.

References

1. McCanny P, Bennett K, Staunton P, McMahon G. Venous vs arterial blood gases in the assessment of patients presenting with an exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med. 2012 Jul;30(6):896-900. PMID 21908141
2. Kelly AM, McAlpine R, Kyle E. Venous pH can safely replace arterial pH in the initial evaluation of patients in the emergency department. Emerg Med J. 2001 Sep;18(5):340-2. PMID 11559602
3. Middleton P, Kelly AM, Brown J, Robertson M. Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emerg Med J. 2006 Aug;23(8):622-4. PMID 16858095
4. Koul PA, Khan UH, Wani AA, Eachkoti R, Jan RA, Shah S, Masoodi Z, Qadri SM, Ahmad M, Ahmad A. Comparison and agreement between venous and arterial gas analysis in cardiopulmonary patients in Kashmir valley of the Indian subcontinent. Ann Thorac Med. 2011 Jan;6(1):33-7. PMID 21264169
5. Ma OJ, Rush MD, Godfrey MM, Gaddis G. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003 Aug;10(8):836-41. PMID 12896883

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Pilot: ALiEM Journal

"...all ideas are second-hand, consciously and unconsciously drawn from a million outside sources..." 

- Mark Twain

Building on our blog's peer review experiment and the discussion about peer-review on various social media platforms, we at Academic Life in Emergency Medicine have decided to take it one step further. 

Dr. Brent Thoma at BoringEM.com initially proposed the idea of a FOAM journal, which would highlight the best blog articles in a peer-reviewed manner. Although his suggestion was an online journal which peer-reviewed blog articles POST-publication, we love the general concept of an online journal with quality content, submitted by various authors. 

Using a more traditional print journal model, we are piloting an ALiEM "journal" on a miniature scale to test a proof-of-concept idea. Can we encourage social media consumers to become social media producers of quality, peer-reviewed content? Each month we will choose 5 articles and post them the first Monday of every month.

Pilot idea for ALiEM journal

• Open call for blog articles relevant to Emergency Medicine or medical education, which would be peer-reviewed by members of the ALiEM blog team ± recruited content expert
• We provide the medium (blog), and you provide the words. We know that some of you would like to write a blog post, but do not have a blog or have the time to maintain an ongoing blog. We would like to offer you that option.

Why submit to the ALiEM journal?

• Through mentorship and feedback, improve your writing skills and the nuances of writing blog posts (different from traditional print articles).
• Communicate and discuss your opinion with others.

• Network

• Get recognized and use on your CV.
• Enjoy the instant gratification of reaching at least 1,000 readers worldwide on the first day of posting.
• Know that your post will live on in posterity.
• Join the FOAM movement.

Topics

• Teachings related to Emergency Medicine 
• Medical education 

Eligibility

• The blog post must not currently be available in print or online. 
• We welcome all writers ranging from medical students to retired clinicians from various professions including physicians, pharmacists, physician assistants, nurse practitioners, nurses, and prehospital providers. 

Peer Reviewing Criteria

• Relevance to EM or medical education 
• Clarity of writing 
• Accuracy of content 
• Based on current literature 
• Overall quality of blog post

Submission Checklist

• Submit article in Microsoft Word. If including a video or podcast, please send the URL link or file as an attachment.
• Ensure HIPAA compliance.
• Write in English.
• Write in short paragraphs. 
• Bulleted/numbered lists improves readability.
• Limit blog post to a maximum of 400 words, excluding references.
• Include 3 relevant images.
• Provide references such as the primary literature, blogs, podcasts, or videos.
• Be aware of copyright material.

Deadlines

• February 25, 2013 for March 4 blog publication
• March 25, 2013 for April 1 blog publication

Submit your blog article to Dr. Javier Benítez (AcademicLifeinEM@gmail.com).

If your article needs a bit more work, we will return your article with some feedback, and you can send it back after you have made edits. If your article looks good, we will post it. During the pilot we will focus on EM or medical education topics only. We will not offer money or guarantee a permanent position as a blogger here at ALiEM. We hope that this experience will get your feet wet into writing and hopefully create your own blog in the future.

Reference: 

1. Thoma, B. (@BoringEM) A journal of FOAM. BoringEM. January 18, 2013
2. Sparshott, A. (@IVLINE) Capturing the Great FOAM. IVLine.
3. Weller, M. The Virtues of Blogging as a Scholarly Activity. The Chronicle of Higher Education. April 29, 2012
4. Wren-Lewis, S. Advice for potential academic bloggers. The London School of Economics and Political Science. January 14, 2013

Image 2 Image 3

Patwari Academy videos: Demystifiying how ECGs work

As a nice segway from the Low Risk Chest Pain videos, below is a 3-part series on Demystifying the Electrocardiogram by Dr. Rahul Patwari. It takes talent to make the complex simple.

How to get an ECG 

(standard, right-sided, posterior)

ECG: From electrodes to leads

ECG: Rate, Rhythm, and Axis

App review: POC Ultrasound Guide

There is a new free app called POC Ultrasound Guide [iTunes link], created by Wexner Medical Center at Ohio State University.

What is it?

This app is as handy as it is streamlined to use, which is the foundation of POC - point of care. The organization makes it easy to navigate and get right to the information you need at that moment. The main applications are listed as aorta, cardiac, critical care, FAST, musculoskeletal, pelvic, and vascular.  Selecting any category will take you to another screen where transducers of choice are listed per exam. Each subsequent page afterwards takes you to a how-to of obtaining each desired image including hand positioning and location of the indicator.

 The best part is that it is FREE!

Pros: 

• Easily could be used in the ED. 
• Useful for junior residents who are looking to practice hand eye coordination. 
• Images have anatomy labels which facilitates learning. 
• Serves as a useful reminder of which windows are needed for each test such as pericardial, perihepatic, perisplenic, and pelvic windows for the FAST. 
• Useful for senior residents and attendings to review with their juniors prior, during, or after obtaining ultrasound images to help with bedside teaching. 
• Has pathology images for each section 
• Clarifies confusing vocabulary such as “seagull” sign. 

Cons: 

• Assumes basic knowledge of ultrasound and physics. 
• Has limited clinical utility for senior residents or attendings with advanced ultrasound training. 
• At times the ultrasound images are dark and the anatomy is difficult to discern. 
• There are not any video clips which would be very helpful in any ultrasound app. 
• No information on DVTs or optic ultrasound. 

A handy disclaimer is a part of their information page. The app is intended for individuals to use it if they are already qualified in the use of medical ultrasound or are students of medical ultrasound themselves. This app in no way replaces any formal ultrasound training.

Overall rating: 4 of 5 stars

I think it will be useful in the clinical area for junior residents. Anything beats carrying around a textbook, or going back to a computer workstation for teaching purposes. I would like to see images with video clips if possible. Did I mention this wonderful app is FREE!

Website: Emergency Board Review

The emergency board in-training exam is a standardized exam that takes place every year in most if not all of the EM residency programs in the United States. It is administered on the last Wednesday in February. The exam is administered by the American Board of Emergency Medicine (ABEM). The knowledge assessed by this exam is what’s expected from residents in their third year of residency. According to ABEM there is a strong correlation between the in-training score and passing of the boards. 

A few physicians who contribute to the online concept of Free Open Access Meducation (FOAM) have gathered together and put a website called:

Emergency Board Review 

Twitter: @EMBoardReview

Facebook: Emergency Board Review page

On this site, they have uplaoaded videos reviewing topics not only for the in-training exam but also for the ABEM boards.

Here's their introductory video:

The website’s content and format make it very user-friendly. These guys have experience taking the in-training exam and the ABEM board qualifying exam as well. Dr. Bob Stuntz is a faculty member and Dr. Steve Carroll is a junior attending are faculty, and Dr. Jon Schonert is a third year resident. The website contains useful links and other learning material. Although, still a work in progress, the quality is top notch. I hope you go visit their site and benefit from this free open material.

Here is one of their lectures: 

Here are their respective Twitter and blog accounts:
Jon Schonert (@emchatter) emchatter.com Bob Stuntz (@bobstuntz) http://www.emrespodcast.tumblr.com/ Steve Carroll (@embasic) embasic.org (only a contributor to the website. Addendum 1/27/2013)

RIME - Evaluating Learners

Accuracy
Valid for practice
True to literature
Overall quality

Background

Lets talk about an effective evaluation process called RIME developed in 1999 by Pangaro. Not only is the name catchy, but it also makes intuitive sense.  

RIME stands for R - reporter; I - interpreter; M - manager; E - educator / expert. It’s perfect for those who want to evaluate in a meaningful and nonjudgemental way that is quick and useful. It can provide structure that is more valuable than saying, “you were awesome today”. Because the tool uses observed behaviors, it allows for the evaluator (you!) the ability to grade based upon what you see. 

What is RIME?

Reporter: Learner who saw a patient and then regurgitated a bunch of facts right back at you. Word vomit, if you will. Sometimes they are fantastic reporters and their presentations are sheer poetry. Sometimes the learner get the wrong facts; sometimes they get too little facts; sometimes they get too many facts about something that is trivial.

Interpreter: Learner who saw the patient, gave you a history and physical exam presentation, and is now able to say to you, “I think XYZ is going on in the patient”. Essentially, the interpreter can synthesize the information that was gathered and reported, and subsequently gives you their thoughts. Developing a differential diagnosis is a good example of interpretation.

Manager: One who can discuss the management and treatment plan for the patient. Sometimes the learner is really off such as saying, “I want to get a stat trans-esophageal echo.” Not happening in the ED.

Educator / Expert: Someone who can report information gathered accurately and succinctly, can infer and interpret meaningfully, can develop a management plan, and finally can discuss evidence and debate important clinical concepts.

Pitfalls

When using RIME, one has to be aware that different levels of learners will be in different categories. For example, you would not expect a first year medical student observing in the ED to be at the level of educator / expert, let alone reporter. At the same time, a good stand out candidate as a future intern could be that fourth year rotator who is knowledgable about the contraindications of beta-blockers in acute MI.  

Beyond RIME

The next step in using RIME is to use what you observe about the learner from your encounter and nudge them into a higher competency level. RIME will let you know prodding questions to ask  For example, a learner who is a reporter may be asked to interpret the information given. This is a way to challenge and allows you an easy way to teach something that is appropriate for the level that they are currently sitting.

References:

• Bloomfield L, Magney A, Segelov E. Reasons to try ‘RIME’. Med Educ. 2007. Nov;41(11):1104. PubMed PMID: 17883381

• DeWitt D, Carline J, Paauw D, Pangaro L. Pilot study of a “RIME”-based tool for giving feedback in a multi-specialty longitudinal clerkship. Med Educ. 2008. Dec;42(12):1205-9. Pubmed PMID: 19120951

• Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. 1999. Nov;74(11):1203-7. PubMed PMID: 10587681

• Sepdham D, Julka M, Hofmann L, Dobbie A. Using the RIME model for learner assessment and feedback. Fam Med. 2007. Mar;39(3):161-3. PubMed PMID: 17323203

If you are interested, you can view the results of this Peer Review Demographics data. 

PV card: Diagnosis of DVT (ACCP guidelines)

Accuracy
Valid for practice
True to literature
Overall quality

A patient presents with an asymmetric leg with trace pitting edema in the affected leg. What is your diagnostic approach to such a patient? What is the role of D-dimer and ultrasound (U/S)? Does this match the 2012 American College of Chest Physicians (ACCP) guidelines?

The first step is to determine your patient's pretest probability because the recommendations vary based on risk. I can tell you that many ED patients come in with a Wells score of 1-2, which places them in the "moderate pretest probability" category. There are 2 approaches you can take based on the availability of resources at your site (high-sensitivity D-dimer or U/S) and the patient's comorbidities. Are you referring your patient for a repeat outpatient ultrasound, if warranted?

Note: This card is not for the workup of recurrent or upper extremity DVTs.

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. Jason West (EM resident at Jacobi/Montefiore) for this card idea and deciphering the complex recommendations from the publication.

References

• Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH; American College of Chest Physicians. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e351S-418S. Pubmed .
• Image source

If you are interested, you can view the results of this Peer Review Demographics data. 

One-dose vancomycin for SSTIs: Just don't do it

Accuracy
Valid for practice
True to literature
Overall quality

Please peer-review this blog post above by clicking on stars.

You are managing an otherwise healthy patient with cellulitis but no abscess to poke. You decide this patient needs antibiotics but is stable enough to go home.

"Give em' a dose of vanc before they go," right?

Here is why giving one dose of IV vancomycin for SSTIs in stable patients is a bad idea:

• NO evidence that this shows any benefit.
• Not recommended by the Infectious Diseases Society of America (IDSA)
• Extends the patient's ED stay by at least an hour for the IV infusion
• Increases the cost of the ED visit (IV line, medication, RN time)
• Pharmacokinetically 1 dose of vancomycin makes no sense for SSTIs

-   1 gm IV x 1 is sub-therapeutic for decent adult kidneys

-   Effective bug-killing is based on drug levels achieved with repeated dosing over several days

• Subtherapeutic vancomycin concern in the age of multi-drug resistant (MDR) organisms
• Check out this 2009 editorial in the New England Journal of Medicine on antibiotic-resistant bugs in the 21st century.

Here is how I subjectively approach consults for uncomplicated SSTI antibiotics:

Some will argue that we should still give SSTI patients one dose of IV antibiotics and send them out on the same PO antibiotics - i.e. clindamycin. Remember that infusion time for IV antibiotics is usually 30-60 minutes, the same time it takes for the antibiotics to be absorbed from the GI tract, so giving 1 dose of IV antibiotics as a "load" before discharge is not necessary. 

Oral antibiotics commonly used for SSTIs and their bioavailability (source - package inserts):

• Clindamycin ~90%
• Sulfamethoxazole/Trimethoprim ~100%
• Doxycycline ~100%
• Linezolid ~100%

Would love your feedback! @ZEDPharm

Reference

Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin. Infect. Dis. 2011;52(3):285–92. Pubmed 21217178

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Trick of Trade: Incision and loop drainage using tourniquet

Loop Abscess Drainage from Rob from ercast on Vimeo.

The technique for abscess drainage traditionally is incision and drainage (I&D). In August 2012, I wrote about incision and loop drainage (I&LD), which it seems has gained popularity over time with similar outcomes.

This technique involves using a sterile vascular loop, which is thin and long enough to form a loose knotted loop. The video above by Dr. Rob Orman reviews the steps.

But, what if you don't have a vascular loop in the ED?

Trick of Trade:
Use a trimmed sterile tourniquet as the loop

Trim the tourniquet longitudinally. This strip was long and thin enough to allow us to tie a non-tensile loop through the abscess.

Reference
Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010 Mar;45(3):606-9. Pubmed .

Tweet Pearls of the Week 1/11 to 1/18

Better viewed on a laptop or desktop fullscreen

Patwari Academy videos: Low risk chest pain

One of the most common complaints in the Emergency Department is chest pain. Is it something serious? How do I risk-stratify patients with potential acute coronary syndrome? What should I be thinking of and not missing?

Rahul goes over the low-risk chest pain patient in 2 great, short teaching videos, based partly on the 2010 AHA/ACC Guideline for ACS risk stratification.

The Socratic Method

Accuracy
Valid for practice
True to literature
Overall quality

“I desire no other epitaph…than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.” -- Sir William Osler (1)

Diagnostic reasoning is one of the most complex, analytical, and intuitive processes to develop in the medical profession. Even seasoned physicians spend a lot of time fine tuning this skill. Although charged with teaching others, some excellent diagnosticians find it difficult to explain in detail how they arrived at a diagnosis or a differential diagnosis. Some might even find themselves in a position in which they have to assess someone else’s diagnostic reasoning. This task is even more daunting since we are not all taught much about this process, even less how to teach it to others. 

One method used to assess this process in medical students and junior physicians is by using the Socratic method, or in what’s known under medical slang “pimping.” Here are four links from the site Life In The Fast Lane where Dr. Chris Nickson (@precordialthump) does an excellent review of the topic of “pimping.”

1. Pimping In Perspective

2. Pimping for the Pimpee

3. Pimping for the Pimper

4. Me as the Pimpee

What is the Socratic method?
It is a learning tool used via dialogue in the form of questions and answers in various fields to impart knowledge. Its purpose is for the questioner (the person with more seniority) leads the more junior person to arrive at the answer through his/her own analytical thinking (the aha! moment). 
It takes someone with the right set of skills to carry this out effectively, even more so in the clinical arena. As Dr. Nickson points out, this process can be a positive or negative experience for all parties involved. Unfortunately those who do not have this skill mistakenly assess diagnostic reasoning by asking students and junior residents by regurgitating information. Regurgitating information has a place in Medicine and it’s definitely the base on which we build upon, but it’s not diagnostic reasoning. Admittedly assessing someone’s diagnostic reasoning is time consuming and a complex process, but it can be done even in a busy emergency department.  

The Socratic method, if used appropriately, expands the learner's base knowledge to the point where not only the learner knows WHAT piece of information he/she lacks but also improves on his/her THOUGHT PROCESS.

On the effectiveness of the Socratic method in medical education, 
Dr. Robert Oh (2) states 3 important points:

Challenge the learner’s preconceived notions of Medicine by asking questions in a logical and stepwise fashion to hone critical thinking skills in the context of the patient. Diagnose the learner’s level of understanding to assess his/her learning needs through questioning Engage the learners- encourage focused self-directed learning strategies or teach clinical pearls.

He also addressed some pitfalls when using the Socratic method:

Avoid ambiguous questions (“Guess what I’m thinking”) Do not use the Socratic method to evaluate a learner’s performance, rather focus on the process. Do not use this method to humiliate the learner as this is not compatible with adult learning.

Being a great clinician does not necessarily equate to being a great teacher, and being a great teacher does not necessarily equate to being a great clinician.

Learning to become an effective teacher in Medicine requires dedication to the craft. People get PhD’s in education. It's not simple or quick to be a great teacher. To presume so is to set up all of those involved for failure (including patients). 

Your challenge is to first be aware of how complex this process is and dig deep into evidence-based education. 

I hope this post helps you gain more understanding on the Socratic method and how it may affect the learning process. If it did add value to your understanding or you have more suggestions on the topic, add your comment below and let us know how to learn and teach more effectively.

References

1. Osler Society of New York http://www.oslersociety.org/index.php/by-osler; accessed January 17, 2013.
2. Oh RC. The Socratic Method in Medicine--the labor of delivering medical truths Fam Med. 2005 Sep;37(8):537-9.

Image 1, Image 2, Image 3 source



If you are interested, you can view the results of this Peer Review Demographics data.