The EMBER Project

Have you noticed a change in your airway box recently?  No, it’s not the new McGrath or C-MAC or any other cool high-tech tool. It’s a more subtle change.

It used to be when you prepared for a sick patient to arrive that you opened up the box, grabbed a handle, and slapped on your go to metal blade to check the bulb before the patient arrived. If that patient didn’t need intubation the blade went back in the box.

Not anymore. Emerging concerns about cross-contamination  and increased scrutiny by regulatory groups has led to some changes in equipment and also a need for changes in practice. Blades need to be appropriately cleaned, sterilized and sealed; once opened they can’t be put back.

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The problem is that the traditional metal blades often had light issues related to multiple use and sterilization techniques – hence the habit all Emergency Physicians have of checking the blade prior to the arrival of a sick patient.

At my institution, the solution has been new disposable blades that are sealed and packaged (and look a lot like the old reusable metal blades) which is why the old habit is hard to break. These disposable blades rarely have bulb issues and there is more than one blade available if you happen to run across a broken one. We also added a non-sterile (not for patient use) blade to check the handle battery function.

So resist the urge to open that packaged blade and check the bulb, because now you can’t put it back in the box. Well, you can but you’ll just be asking for a JAHCO citation.

The Bundle – Clinical resources you can use

Five Things The Joint Commission Thinks You Should Know About Laryngoscopes and Endotracheal Tubes by Linda Hertzberg, M.D.

Maintaining your learning stream (your customized flow of educational content) is a key part of being an  effective lifelong learner. Even in the age of FOAM the center of your learning network can become heavily weighted towards just a few resources; which is why taking the time to search periodically for new ones should be as routine as cleaning your hard drive.

Content sources within the FOAM universe are of course easier to find, but this can become a self-referential system, and so I try to spend time periodically looking for relevant but unusual places with new learning.  The Autopsy Center of Chicago blog is one of those.

Autopsy rates have declined dramatically in recent decades, and the valuable feedback they provide for clinicians has declined with them. According to the CDC, overall autopsy rates have dropped more than 50 percent since 1972. That number gets worse if you look just at autopsies performed for disease related deaths.

While autopsy rates may be declining, in a hashtag world, the potential knowledge to be gained from them doesn’t have to. The Autopsy Center of Chicago has a blog that presents interesting monthly cases, and offers a view into the pathologist’s post hoc world I find fascinating and educational. Sure, it’s not like getting autopsy results on your patient, but there is still plenty of educational value for clinicians here. It also has some unexpected features, such as insight into family motivations for wanting an autopsy, and the emotional value they contain.

Aortic rupture presenting as hip pain

Looking at this site makes me wonder why there isn’t a national autopsy registry with regular updates for clinicians on what is being discovered about the diseases we treat, mistreat, or just miss all together. In the meantime, I’m adding this blog to my favorite Flipboard feed.

Sorry, I couldn’t resist the urge to throw in some 70’s medical television on this one.




Are They a Good Choice?

By – Lucy Willis MD

Low back pain is an extremely common ED complaint, for which opiates are frequently prescribed. The last 20 years has seen the development of an opioid overdose epidemic. The rate of death from prescription opioids has increased fourfold and is now higher than heroin and cocaine combined.overdoseeveryday-450w

As emergency physicians, we are are always weighing risk/benefit ratios when making treatment decisions, and this is now a complex task when it comes to treating pain. There is a lack of literature demonstrating the effectiveness of opiates for the treatment of low back pain. ( See ACEP clinical policy on Opioids).

For our first NYP LM Journal Club, we are reviewing the recent JAMA study, Naproxen With Cyclobenzaprine, Oxycodone/APAP, or Placebo for Treating Acute Low Back Pain. This was a randomized, double blind, 3 group study carried out in an urban ED in the Bronx. Patients with nonradicular acute low back pain were randomized to either naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/APAP.

The primary outcome was an improvement in functional outcome at 1 week. There was no difference between the 3 groups! However, there was a trend toward benefit in the oxycodone/APAP group as they were more likely to report pain levels of mild or none, with a NNT of 6. However, if you balance this against the NNT of 5 for adverse effects (drowsiness, dizziness, stomach irritation, n/v) and the potential for abuse, the authors of the study conclude that their study does not support the addition of these medication to NSAIDs in this setting.


#Postards from the ED

There are educational courses and there are inspirational courses. I had the opportunity this weekend to participate at BASE Camp. The brainchild of Kevin Ching, it’s an amazing and unique two days of education.

For those of you who don’t know about this great opportunity, it is, as the website says:

a high-intensity, fully immersive weekend of simulated pediatric emergencies where fellows and nurses work together in multidisciplinary teams to manage critically ill and injured children and adolescents

BASE Camp certainly lives up to this, but perhaps the best aspect of the course is the amazing feedback participants get after each case.  By the end of the second day it was moving to see the sense of common purpose and renewed enthusiasm for what we do every day that was clearly visible in all the participants. As I said, there are educational courses and then there are inspirational ones.  This one is definitely both…


#Postcard from the ED

This throwback post takes us way way back to the late 70’s. Dr. John C. Grammar Jr was a cardiologist in Dallas. Texas. He was also apparently a very passionate educator and all around funny guy. I had never seen this video before, but someone updated it with a new soundtrack, and this morning it drove me into paroxysms of laughter (I will never look at cardiac arrhythmias the same way).

It also illustrates that learning can be fun – indeed it’s often more powerful when it’s fun. Reviewing p-values, dissecting research methodologies, rote memorization and sober lectures will always be part of medical education, but interspersed in there we should remember that being passionate about medical learning doesn’t require taking all the joy out of it.

Thanks to Dr Grammar for still teaching and entertaining us after all these years, and thanks to all the passionate medical educators who put the time and energy into projects like these for the sheer love of medicine and joy of teaching. I highly recommend you get up and dance to this one.

The Bundle

@LITFL Music, art and education in syncopated juxtaposition here

Hey, can I get a  jazz riff — New York style please?

Music everywhere 🗽🎁🎉😎🎺🎷🎺🎶 #music #busking #NYC #rtrain

A video posted by Jonathan St. George (@jstgeorge) on

I’m excited to announce that “The Protected Airway Course” now has a home, and the first of the teaching modules are coming online. Our annual Airway & Difficult Procedure Course lasts only two days (and is only available for our EM residents, critical care and PEM fellows) but this learning is 100% FOAM certified, farm to table fresh. And it’s available anytime!

In the coming months we will be translating airway knowledge from our experts around the EM and critical care world and posting it here for you to enjoy. We’re hard at work creating engaging, innovative, interactive tools to teach key topics in airway management that will augment the course and allow for self-paced learning. In each module you will find learner focused tools designed to make the content stick such as:

  • A self assessment quiz to get you started, and make your studying more focused.
  • Bundled multi-media learning tools covering all aspects of the topic.
  • Strategically placed bite sized notes, video clips, and slides to drive home and highlight core concepts.
  • A quick “Summary in 5” podcast from our knowledge leaders for a quick review on the subway home.
  • Guest posts and interviews with our airway experts from around the city, the country, and the world.
  • Some surprising and entertaining bonus airway goodness (I don’t want to spoil it, you’ll just have to check it out).

This month our flagship module is the emergent cricothyroidotomy. This procedure presents many educational challenges: It’s high stakes, low-frequency and performed in the stressful failed airway situation. If you don’t think about it, prepare for it, or feel confident doing it, you will fail to perform this lifesaving maneuver in a timely manner. The goal of this module is to get you on the path to learning not just the procedure but all the tangible and intangible skills required to master the failed airway scenario.

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But wait, that’s not all!  Since airway education should be all year long, and come in all shapes and sizes, we have several new resources for you to get airway pearls straight to your mobile devices.

  • Flipboard magazine to collect all the latest posts and curated airway content in one place.
  • A new “Airway Tools to Live By” page demonstrating new airway tools as we test them.
  • You can follow along on the Airway Tools page or directly on our Instagram account.

A Mac blade for the Glidescope. Cool #airway #nypem

A photo posted by Jonathan StGeorge MD (@emberproject) on

The next module should be out next month but we’re understaffed, overworked, and underpaid so be patient as we bring new content to you at regular intervals. :)

In the meantime. May the airway be ever in your favor!

Some of you may have noticed that The EMBER Project’s site has a new look. Don’t worry the blog is still here (you can find it on the sliding menu above) but we are prepping for some exciting new changes, including a complete set of innovative teaching modules designed to complement our airway course, a podcast, as well as several other new features that required a more robust platform.

Most of the new pages are not ready for use but feel free to look around, we’ll let you know when the new content starts coming online.

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