Monthly Archives: March 2012

Notecards In Verse

More emergency medicine literature in verse, inspired by a new Remington-style typewriter app on my iPhone.  The clinical pearl, along with the reference literature can be found by clicking on the card.


Tools to Live by – Infectious Disease App

My recent post about subjectivity in clinical practice, and its central, but often maligned status in current medical literature has inspired me to highlight some tools that I find particularly useful because of the subjectivity infused into them.  The list is long, since in my opinion it’s what makes the new online technology so successful as an educational tool. Not the wealth of objective information, but the fact that it is suffused with subjectivity and personal insight.

My first taste of this was with the podcasts offered by Mel Herbert of EMRAP & Co.  When they first came out I couldn’t get enough of them, and initially (other than my fascination with the Aussie accent) I couldn’t put my finger on why I found them such useful learning tools.  Wouldn’t I find much of the same information myself by opening a textbook or reading the same journal articles? Well, no.

I came to realize that it was the Subjectivity of the presenters that was the true value in the podcast’s content.  I haven’t quite come up with a name for what to call this, but there is definitely some kind of contextual or experiential higher order learning taking place – something that can only come into existence when you integrate knowledge, experience, and subjectivity.

Imagine, a study that supports a certain group of patients getting thrombolysis in stroke may be of some value.  That same study filtered through the experience of a clinician who sees emergent stroke patients daily, who knows how to navigate the million challenges that stand between diagnosis and therapeutic intervention, and can help you integrate the new information into your current clinical practice?  Priceless.

Is Subjectivity is flawed? Yes.  Understanding where it’s succeeds, where it fails us; where it can fly on its own and where it needs support are all open to continued personal reflection and objective evaluation. The issue is not that it’s flawed and needs replacing with “evidence” or technology, but how best to hone it into a powerful clinical tools with the support of technology and EBM.

But this post is not really meant to be another pitch for why subjectivity sits front and center in the house of medicine, and all our science and technology serves at its pleasure. It’s about great tools that highlight the clinical value of subjectivity.  So here’s one for you.

Infectious Disease Compendium. A Persiflager’s Guide. Is an example of the value added to a clinical tool when it is infused with the author’s point of view.  It has humor, and some silliness, but it also has insight, perspective and personal context that transforms a dry Sanford guide style reference chart into an interactive app that’s as close to having an ID consult with you on your shift as you can get.

Download this app, flip through some of the sections and you will find pearls to guide your decisions beyond the usual “if A then B” of most reference guides. No doubt some of this experiential knowledge will benefit your patients, make your shifts in the ED easier when angsting over a difficult antibiotic choice, and maybe help that ID doctor in the morning figure out if the bottle of gram positive organisms growing from your admitted patient’s blood culture is a contaminant or something he really needs to worry about.


The EMBER Project Reaches 1000!!!

Recently my little online outpost passed 1000 visits.  Thanks to everyone who helped me reach that milestone.  I’ve been having a great time sharing my ideas and getting feedback from readers, and it’s been amazing to get responses from Australia to Bolivia to Norway and a dozen other countries.

From the beginning the goal has been to curate a conversation about Emergency Medicine in a way that challenges traditional didactics, explores the tools we use in our daily practice from a new perspective, and puts our well-being as EPs front and center.  I hope to keep developing these ideas and posting more content for you to enjoy over the months and years to come so stay tuned.

Now also seems as good a time as any for some self promotion.  Little blogs like mine need all the help they can get, so please go to our Facebook page and LIKE  us, follow through our RSS feed, or Twitter and get the word out to friends and colleagues who you think may find this site interesting so it can grow.

Thanks

Jonathan St. George MD


Notecards in Verse

Inspiration comes from the strangest places.  Yes, I studied English and Philosophy as an undergrad, but I wouldn’t have considered iambic pentameter as a tool for EM education.  Then again, if you asked me whether I preferred a mnemonic to a good limerick for remembering important information I would definitely take the limerick.

Then I stumbled upon a beautifully creative new app from Doormouse mfg, that recreates the beauty and imperfections of an old-fashioned Remington on your iPhone.  Go to their website and check out the creativity of some of the cards in their gallery. Here are some of my favorites to give you an idea of how creative people can be if given the tools to play with.

Once I bought the app for myself, I was addicted, and couldn’t put it down.  I started sending type-writer notes on the app’s “high quality card stock” to people, and was amazed at the responses and positive comments I received.  There is something elusive and fascinating about what sticks in our brains and what passes through unnoticed.

Why my next thought was Emergency Medicine notecards made in this fashion deserve to be in verse I can’t explain. But here we are. This card is based on a study by K. Inaba & Co about chest tube size in trauma.

So here’s the deal.  Each card embodies some key concept from a recent paper in the EM literature I’ve read.  Usually, it will be in verse, but not always (now that I’m a temperamental artist a can’t be bound by such rules)  Click on the card and go to my shared Evernote folder where the reference literature from which the questionable gobbet of educational doggerel was created a gallery of similar cards are available.  I’ll keep adding them as long as the Bard continues to inspire.

Type written cards in verse may not be the answer to all your learning needs, and if you recite them on rounds you may get odd looks, but you can be comforted by the fact that any step closer to the company of William or e.e cummings, and away from Powerpoint is a good one.

PS. if you want to try your hand at a few of these cards yourself just download the app, email your cards to me, and I’ll add them to the collection.  I’m sure a “Selected Works of Poetry in Emergency Medicine” is just a few lyrical verses away.


The EMBER Project’s Education Manifesto – An Introduction

An underground handbook for surviving and thriving on your shifts as an EP

BPP - Oakland 1969

There is a knowledge gap in Emergency Medicine.  It lies within the difference between the way we teach and the way we learn.  Bridging this gap is the EMBER Project’s educational manifesto of sorts.  It starts with the belief that our continuing education as Emergency Physicians should not be an endless continuation of the traditional didactics we’ve become accustomed to in our formal training as physicians. Instead it should be a more complete and thoughtful examination of what makes us successful in our daily EM practice.

Over time we become suffused with a host of accumulated skills, knowledge, wisdom, tools, and relationships, and we develop conscious and unconscious strategies for success in the emergency department. Sadly, most of this knowledge is not recognized by us or even taught to new physicians, and falls into what I like to call the “crash and burn” school of medical education.

Perhaps because we have had to learn much of it by personal experience, we have difficulty recognizing its central importance in our development as good physicians – much less being able to describe how we became proficient in these areas to others. Teaching is a skill.  We learn by watching others.  I learned how to teach ECG interpretation by being taught by someone else, but how do you teach skills that have never been taught to you?

The second tenet of the manifesto is that physician well-being and patient care are inextricable.  Success in Emergency Medicine starts with accepting that our physical and emotional resources are finite, and that the practice of Emergency Medicine is challenging. For generations I believe that publicly acknowledging our limits and the fear that we will be seen as lazy have been conflated in our profession.  The stereotype of the tireless physician and the fall out from this impossible ideal still haunts us.

We have limits, rather than ignore them, we must learn to minimize the impact  of those things which are a drain on us, and maximize the supportive resources we have around us.  Doing this well is part of becoming an efficient practitioner of the EM art, and is essential to longevity and well-being in our profession.

The Smooth Sailing series takes both of these concepts to heart.  It is a re-examination of our development as Emergency Physicians from a personal well-being perspective, in order to define the strategies that help us develop a sustainable career of continued growth, improve how we care for our patients, and getting you home at the end of hard shifts happy and healthy.

I’m excited to begin exploring what makes us successful and healthy emergency physicians in this series.  I hope you find it as useful and interesting as I do, and that you will share your insights and comments with me along the way.  Perhaps in discussing how we acquire these skills they will become part of a more conscious strategy for success that we will be able to pass on and teach to others.  Stay tuned, the first chapter in this series is coming very soon.  In the meantime please check out the last Smooth Sailing post to get an idea of where we’re headed.


Tools to Live By – EVERNOTE

I’m forever trying to find better ways to collect and organize the emergency medicine resources I find valuable.  Over time the tools to do this continue to get more sophisticated. There are really three things that are essential for a good organizational app. It must be easy to use, it should be accessible across multiple platforms, and it has to have the ability to share and manipulate stored files. Evernote has all of this in spades, and may be the only app you need to keep your digital EM life organized.

In an earlier post “Keeping it Together” (where I talked about tools to help you get organized for the next time you need to get to be credentialed) I highlighted Dropbox and Google Documents as organizational tools. I still use both of these for cloud storage and sharing, but neither of them has the elegance or sophistication of Evernote’s interface when it comes to quickly inputting and retrieving audio, notes, pictures or any other digital snippet you need to stash away for later.

One of the features I’m exploring now is Evernote’s ability to share folders. This feature has a great deal of potential for EPs to share and collaborate in a less static format. For example important protocols (like which patients fulfill criteria for tPA in stroke) can be updated and shared in this way, allowing physicians at the bedside to always have the latest version on their mobile device.

My favorite shared folder at the moment is from Michelle Lin and her Paucis Verbis cards on the Academic Life in Emergency Medicine Site. If you are playing around with Evernote and want to get these cards click here for the link on how to do it.  By the way, congratulations to Dr. Lin for passing the 100 card milestone.

If anyone has any great Emergency Medicine related folders they want to share or have other uses for Evernote related to EM please let me know and we will put it up here for everyone.

The Rules of the Road

One of the things I’ve learned in Emergency Medicine is that if we don’t define ourselves then others will be more than willing to do it for us. The struggle to set the driving principles and priorities of our profession occurs in a thousand places; in a thousand different ways every day, and all of us are acutely aware how these struggles can impact the quality of our practice. That’s why it’s so disconcerting to see a trend within our speciality that potentially undermines us as clinicians.

In the current issue of Annals of Emergency Medicine, Dr. Schriger and Dr. Newman have teamed up to write about risk stratification tools.  Their motivation for the piece is in response to a concomitant publication about a potential biomarker for defining low risk head trauma, and the possibility that it could reduce the number of head CTs we order in these patients.  Here are the key points of their article.

  • There has been a huge proliferation in clinical decision tools that attempt to define low risk patients in the Emergency Department.
  • Many of these tools are poorly designed, and based on false assumptions about physician judgement, subjectivity, and why tests are ordered.
  • The overall benefit of these tools is questionable without a properly defined, clinically relevant method of evaluating them against physician evaluation alone.

The article is a call to reform our methodology but it’s also a plea to address some of our deeper assumptions before we run ourselves off a cliff with decision tool driven testing. The flawed assumption goes something like this:  clinical judgement is subjective and therefore imperfect.  The answer then is to find another more objective tool to save us from ourselves.

This strange desire to want simple answers for complex problems belies the fact that all tests are flawed, and that subjectivity is itself a tool that can be tested like any other.  It also ignores the fact that in the face of complexity sometimes there is no better tool than subjectivity.  It is a finely tuned  instrument developed over millions of years to absorb data and make quick and successful decisions in the face of rapidly changing information. Combine this with years of training and experience and it becomes a powerful foundation for most of what we call the practice of medicine.

Praising subjectivity is not a nostalgic plea for a return to the days when a doctor had only their experience and clinical exam skills to inform medical decision-making (these too are just imperfect tools) nor is it antithetical to the practice of best evidence. It’s simply a request not to “systematically discount”  doctors clinical ability in the name of progress, or burden us with expensive, cumbersome, or difficult to remember rules when clinical gestalt might work just as well – if not better.

Subjectivity, as Dr. Schriger and Dr. Newman elegantly point out, is inextricable from the process of medical decision making, and attempting to build an intellectual bypass around it with decision tools is a road to nowhere.

References:

Medical decision-making: Let’s Not Forget the Physician, David L. Schriger, MD, MPH, David H. Newman, MD. From the University of California, Los Angeles, Los Angeles, CA (Schriger); and the Mt. Sinai School of Medicine, New York, NY (Newman).



Tools to Live By – iPhone Calculator Tip

In a highly technical world, sometimes it’s the little things that are the most frustrating. Take for example, my Google Calendar which refuses to ever display the right local boarding time for any of my flights, or the DVR telling me it can’t record both, The Daily Show and then Late Show because Time Warner’s program guide says TDS ends at 11:32 and thus represents an insurmountable conflict of space and time (where is Neil DeGrass Tyson when I need him).

And then there’s the iPhone calculator. You know, the one where several functions into a calculation you punch in the wrong digit and have to start all over again. Wait, don’t touch the C key! It turns out you can swipe to the left or right over the numbers and erase that last pesky misplaced little digit. I really want to shake that programmers hand.


RUSH – Excelling at the Bedside

One of the areas that Emergency Medicine excels in is the rapid assessment of patients at the bedside, and as such it makes sense that we should be leaders in innovations that help bring this skill to its apogee. In an upcoming post I will talk about this more, but for now suffice it to say that it is one of the reasons I love ultrasound, and in particular the RUSH (Rapid Ultrasound for Shock and Hypotension) exam as an example of what we should be striving for.  I’ve just spent the afternoon reading:

The RUSH Exam 2012: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill Patient, by Phillips Perera, MD, RDMS, Thomas Mailhot, MD, RDMSa, David Riley, MD, MS, RDMS, Diku Mandavia, MD, FRCPC  The RUSH Exam 2012.  The RUSH Exam 2012 (annotated version)

For those not familiar with RUSH, it is the FAST (Focused Assessment with Sonography for Trauma) exam, along with other familiar cardiovascular ultrasound techniques, to rapidly assess the patient in undifferentiated shock.  But this simple explanation belies its true genius: by applying concepts in physiology, with bedside clinical acumen within a structured collection of ultrasound imaging techniques, a powerful diagnostic tool emerges. I’m a big fan of this innovation, and hope we will see more of this creativity in the future of our specialty.

The above article is a bit long, so I’ve annotated and highlighted a copy of it to emphasize what I think are the most relevant parts for a practicing EM physician who already has decent ultrasound ability. I’m also bundling a few other resources on the topic so that you can really get familiar with the exam.  In my experience you have to reach a certain comfort level with a technique before it can become a part of your daily practice.  After that its smooth sailing.  ENJOY.

  • Sinai Emergency Medicine Ultrasound @http://sinaiem.us/   This site has a bunch of great tutorials on all the aspects of the exam.
  • I am not familiar with the detailed evolution of the RUSH exam in its current form, but Scott Weingart MD over at EMCrit.org has been a leader in this area for nearly a decade now and his site has a great overview as well as an audio lecture on the topic that is well worth listening to.
  • All LA Conference lecture on “Undifferentiated Hypotension” by Ravi Morchi MD.  This is a great lecture that pulls together all of the physiology concepts involved in the RUSH exam to bring it all home for you.

The Daily Cup

Thanks to my NP friend Theresa Salerno for the Daily Cup pick of the week.  For all my EM coffee geeks out there watch and learn.

By the way congratulations Theresa on getting your NP degree, between work and school I know you and coffee are good friends.


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