Author Archives: jstgeorgemd

About jstgeorgemd

Assistant professor in emergency medicine with academic and community experience. Interests in medical education/innovation, writing, international medicine and humanitarian assistance.

Design Challenge Innovators

learning-light-bulbYesterday was our EM Innovation in Education Design challenge.  We had participants from our faculty and residents, and also some really talented medical students on their sub-internship with us.  After a presentation on 21st century concepts of learning and teaching, and a brief workshop on some new tools the teams let loose and had just a few hours to design and create.

Along the way we discovered many hidden talents and I was amazed at the skill level. The day was fun, energetic, creative, entertaining and educational.  Thanks to all the participants.

I think my favorite of the day was the ‘six second” design challenge using Vine. This series of making tools from everyday ED supplies was one of my favorites. Congratulations and thanks to  Frank FerraioliMichael SpignerRyan O’Halloran, and Thomas Yang the design team responsible for creating these.

“Where there is interest there is learning”


EM Core Content Design Challenge

The EMBER Project’s Design Challenge is on!  We want to bridge the education gap, move beyond just a few adopters of FOAM, and encourage physician educators of all levels to integrate key concepts of 21st century learning into their tool box.

So we will be challenging our residents and faculty to throw away their Powerpoint slides, learn about new tools, and create core EM content that best embodies the spirit of teaching for 21st century learners. The design challenge has already begun and will culminate in an eight-hour workshop to help you develop and complete your ideas. The deadline for posting submissions on Google+ is 3pm August 19th. A panel will select the best examples of innovative EM FOAM content and highlight them on our blog.

Ahead of the day I’ve been curating many original and inspirational examples of EM FOAM content and the tools used to build them here on Flipboard (two of them are used in this post). For more on what this is all about listen to the podcast link below and check out the rules here.

Sorry this is only open to our residents and faculty, but the winners of the challenge will have their work and ideas highlighted here, so I’m looking forward to presenting some great EM FOAM content next week. If your one of our residents or faculty don’t forget to RSVP at the Google Event link so we can make sure there is enough food for everyone.


Zen Airway and Poetry Inspired by Haiku Deck

There are many reasons to love Haiku Deck. For educators it’s an easy way to free your knowledge from the Powerpoint prison on your hard drive, but it also challenges you to get to the point and hone your educational pearls into shiny drops of educational poetry.  So here is my latest Haiku Deck, part of a series for our airway course teaching modules. I was so inspired I wrote a Haiku to start things off.

The Airway is hard

How sweet the Grade One view is!

Tips for you there are

Enjoy

Oh, I don’t have any money invested in Haiku Deck (wish I did). I just really like it.


Sick Or Not Sick? An Essential EP Skill

A new series is here on the EMBER Project and a new educational tool. Check out the post below for both! And don’t forget to take the quiz when you’re done.

sick-or-not-sick-safe-discharge-education-presentation-odIeAdSMLx

Click here to go directly to the educational content.


One of the toughest challenges in medical education is identifying and articulating the intangible skill set that is essential to every practicing physician.

A key skill required for working in a busy Emergency Department is the ability to rapidly assess whether or not the patient in front of you is sick. Is it the elderly patient with an acute change in mental status or the chest pain patient with diaphoresis? We are required countless times a day to hone in rapidly on the potentially sick patient based on a panoply of subtle and often intangible cues. Over time we become so good at it that a patient who simply has “that look” rolling by on a gurney is often all that is required to get us running to the bedside (that’s a figure of speech, no running please, it makes us EPs nervous).

We also ask residents to learn the “sick or not sick” skill. In the ACGME educational milestones it is a cornerstone of competency. But do we really teach this skill or is it another one of those intangibles that we imagine only trial and error and experience will provide? I often ask talented colleagues how they make the call of sick or not sick and find they have trouble articulating what goes into their almost instantaneous decision-making process.

The “Sick or Not Sick” series is a set of posts designed to elucidate what goes into honing this key skill. To help those learning it bypass some of the trial and error, and make tangible those things that experienced EPs do on a daily basis without articulating it.  I’ve decided to go in reverse order so the first one of three is really the last one “surviving discharge”

Culled from a recent qualitative analysis of patients who died within seven days of discharge from the ED, the moment of discharge is often a final opportunity to “get it right”. Many of the identified risk factors will be familiar to experienced physicians; some may be new and warrant integration into your practice. Either way, in a world of hospital overcrowding, inpatient service pushback on admissions, and pressures to make patients happy in the face of long delays its nice to have some evidence supporting what you already know is right.


 

The EMBER

Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge

New Educational Tools

Haiku Deck.  Make your knowledge more accessible, more visual, and more learner focused.  I’m a fan, and this platform will be highlighted at our upcoming Innovation in Education Theme Day  at NYPEM


The Changing Paradigm of VTE Care

The EMBER Project is having a good day. Despite the cold and snow on our first day of spring, it’s also the first of what I hope will be many new broadcasts using the Google+ platform.  I’m excited about the potential of adapting this tool for medical education. In an era of specialty care, disease entities intersect with multiple disciplines, and optimal care often requires a collaborative approach.

Venous Thromboembolism is one of those diseases that crosses most specialty boundaries. I was lucky enough to get Dr Akhilesh Sista to talk about the changing paradigm of VTE management, and to answer my questions about novel oral anticoagulants, endovascular interventions for post-thrombotic syndrome, and who needs a hematology referral. There are lots of great pearls in this talk. You can view it from the Youtube link above or here on the Event page which will give you the show note links to other great bundled educational material.

The EMBER Project reflects my interest in technology’s ability to enhance the culture of learning and expand our conception of a community of medical educators. Blogs, podcasts, and other social media platforms continue to break down traditional institutional and geographic boundaries, and Google broadcast is another tool that’s especially suited for multi-disciplinary discussions on common disease entities when a team-based approach that does away with traditional specialty care boundaries just makes sense. I’m optimistic we are working towards a time when there is no “upstairs care” or “downstairs care” only good care everywhere.

I hope you enjoy this first broadcast. Please forgive any technical flaws as I work out some of the kinks. Thanks again to Dr. Sista for being such a good sport!


Why is the CDC Still Selling Tamiflu?

In a recent post I asked,” Who are the Stewards of Healthcare?” The CDC comes to mind. Its roll to protect the public from diseases both new and old make it an important pillar of our public health system. The CDC was certainly trying to fulfill its role last week when it notified us about emerging concerns that this years flu vaccine might have reduced efficacy due to antigenic drift. Despite this news, the vaccine may still have some efficacy and likely remains a useful tool in the prevention of influenza and its complications.

This CDC update unfortunately also came with a marketing plug that couldn’t have made the makers of Tamiflu more ecstatic:

Because of the detection of these drifted influenza A (H3N2) viruses, this CDC Health Advisory is being issued to re-emphasize the importance of the use of neuraminidase inhibitor antiviral medications when indicated for treatment and prevention of influenza, — CDC advisory 12/4/14

Apparently, the CDC felt this was a wonderful opportunity to throw its weight behind a dubious class of drugs, and does not feel obliged to protect the public or precious healthcare dollars from unscrupulous drug companies. If you go to the CDC website it seems that despite all evidence to the contrary, antivirals to treat flu should be taken early and often by almost everyone.

“Can flu be treated” they ask? The answer is YES. Who should take it? If your young, your old, your really sick or you just want to feel better, then take it. Of course the page is careful worded, to avoid criticism, but the implication is clear: if your a doctor  prescribe this drug; if your a patient ask for it. If you don’t you’re not following standard of care. Many doctors who read this, will hear “give it to your patients, come on what’s the harm, and if you don’t, then won’t you feel terrible when you realize it’s your fault Mrs Smith’s grandmother died because she didn’t get the Tamiflu?” This type of powerful marketing is what continues to make Tamiflu a multimillion dollar bonanza for its manufacturer.

Yet this flies in the face of everything we know about the drug. Current evidence shows it is not preventing disease, or saving lives, or even preventing complications of the disease. In fact some of the evidence is still being hidden by the drug company who makes Tamiflu, and unpublished negative studies that the company hid for years had be forced into the open.

You expect drug companies to aggressively market their wares, but the CDC is entrusted to hold the public interest above all things. Given the recent FDA furor over Zohydro and its approval of this potentially harmful drug (against the advice of even of its own independent advisory panel) it makes you wonder if now the CDC can also be trusted when it comes to its drug approval process.

Endorsing drugs like Tamiflu with no strong evidence of benefit, drains the system of critical resources and fills doctor’s offices and ERs with patients who have an expectation of getting ‘the Tamiflu prescription” –while they inadvertently spread the virus around to others — it undermines public trust in an important institution, and reenforces the idea that marketing and corporate influence come before public health and safety.

What can we do? Hospitals and doctors should be taking the lead on upholding the public trust if the CDC won’t. Talk to your peers, review the evidence, and define a department or hospital policy. Give doctors support to do what they think is the right thing based on the evidence, not on CDC recommendations. Most importantly talk to your patients so that they can make informed decisions.

The Cochrane Collaboration

Bottom Line

  • Reduced mortality: NO
  • Prevents hospitalizations: NO
  • Makes people feel better faster: maybe slightly, but trade of off is about an equal number of bad side-effects (fewer days with fever and mylagias more with nausea and vomiting)
  • Helps high risk or sicker people: NO
  • Industry sponsored research: YES
  • Negative research results were hidden or suppressed: YES
  • Drug has been aggressively marketed for everything from the flu to bioterrorism preparedness, wasting millions of healthcare dollars with no proven benefit: YES

Surgical Airway Summary

tumblr_m4shyetv9g1r3fh2ko1_500_large

Our online walkabout on the emergency surgical airway is coming to an end. I hope you’ve found this helpful, I know I enjoyed doing it. The emergent cricothyroidotomy presents many educational challenges. It is a high stakes, low-frequency procedure performed in the stressful failed airway situation, where time is not on your side.

Preparing yourself for this scenario requires several key technical and non-technical skills outlined in summary here:

  • A working knowledge of airway anatomy and the confidence to quickly identify important anatomical landmarks.
  • Familiarity with the necessary procedural skills – ideally practiced and reviewed in cadaver as well as sim labs so that the muscle memory is there when you need it.
  • Situational awareness: a term that encompasses the logistical, emotional and psychological skills necessary to take appropriate and effective action. In this case it is defined by how effectively you can identify the failed airway and move through the failed airway algorithm in order to put scalpel to skin. It includes the recognition of normalcy bias and focus lock and the danger of repetitive attempts at laryngoscopy to the hypoxic patient,

This exercise is not a substitute for good clinical training, rather it is designed to highlight key concepts by drawing together disparate online resources into a coherent and educational narrative. As the name EMBER Project (EM Bundles & Education Research) suggests, our goal is to provide bundles of educational material and to discover innovative ways to bring it to you. This time. the entire bundle of resources presented over the last couple of weeks, along with commentary and opinions from other physicians and experts will be up on the EMBER Project’s Facebook page and on Storify today for review – and for future reference. Please join the conversation and add your insight. Until then, may the airway be ever in your favor!

 

Enhanced by Zemanta

Follow

Get every new post delivered to your Inbox.

Join 445 other followers

%d bloggers like this: