Tag Archives: Education

Surgical Airway Summary

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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!

 

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Who are the stewards of healthcare?

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I met a father yesterday in our ED who didn’t want antibiotics for his child’s otitis media.  He had read that a wait and see approach with appropriate analgesia might be a better option, and I was reminded that better stewardship of our healthcare is everyone’s concern.  It made me so happy to see a parent making such an informed choice, rather than thinking to myself (as I sometimes do) about how bad my Press Gainey score was going to be for being “the idiot doctor who didn’t want to give my child antibiotics for an ear infection”.

Our healthcare system is like recycling, carbon emissions or government spending: everyone agrees we should do more with less and be better stewards in theory, but when it comes to practice it’s always someone else’s problem. Is it because the system is so large we don’t feel that our actions matter, or do we feel entitled to use the resources we have, even if they offer no clear benefit to our patients? I don’t know the answer to this, but I do know that I still do unnecessary tests everyday in the emergency department.  Some are because of my concerns over missing disease in low risk patients, some are because I’m following “standard of care” or “best practice” based on poor evidence, some are because specialists want them or won’t admit or see the patient without them, sometimes its the end of my shift and it’s the path of least resistance.

The list of why unnecessary testing occurs is long and the vigilance required to stay on course and do what I think is right for each individual patient and the healthcare system as a whole is enormous.  In fact I would say a large percentage of my education time and practice is devoted to this one task.  The difficulty is in finding the support and resources to continue the process of informed and judicious use of medical resources against the onslaught of demands made by an avaricious, RVU/procedure driven, and risk averse healthcare industry.

The New York Times posted on a great resource for both patients and doctors that I believe is worth mentioning.  It is a list of the most commonly overused tests in seventeen different medical specialities.  Emergency Medicine is not one of the specialties listed (although it should be), however there are many emergency department relevant tests listed among the various specialty lists. I find this resource particularly helpful in stemming the tide of what other specialists ask of me in my Emergency Department (like PPI for GI bleed or pre-op echoes in cardiac patients) and in making decisions for why I’m admitting a patient.  If my major reason is an expedited workup with one of these unnecessary tests then perhaps I will think twice.

For example here are the top five recommended DON’Ts from the American College of Radiology:

1. Don’t do imaging for uncomplicated headache.

Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

2. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.

3. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

4. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.

5. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.

The other seventeen lists are just as good and have a great deal of information relevant to our daily practice.  Of course no list trumps clinical judgement.  The environment we work in, the prevalence of a certain disease in our community, the quality of our tests, and our testing threshold should ultimately determine what we order and what we don’t, but having the support of other specialty societies to NOT do tests is a welcome resource. Along with sites like The NNT and EMLITofNOTE it is another tool to continue improving our daily practice.

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Case Reports from the ED

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Note the subtle venous congestion and edema of the right hand and wrist in this patient with an upper extremity deep venous thrombosis (Paget-Schroetter Disease),

Here is a slightly different twist on Virchow’s triad, and one that I had not seen before until yesterday:  a spontaneous upper extremity DVT (Paget Schroetter Disease) in an otherwise healthy person with no risk factors.  It’s uncommon, but not a complete zebra.  The pathophysiology and subsequent management also differs from your traditional DVT, so I thought it was worthwhile to highlight some of the features that make it unique.

The EMBER Project.003

The EMBER: as always, a collection of interesting information about this topic from around the web.

Paget–Schroetter disease – Wikipedia

First rib resection for Paget-Schroetter Syndrome – YouTube

Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome) - Up To Date

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Postcards from the ED

Upper Extremity Hematoma

I was going to use this post to talk about potential spaces in the body until I made the mistake of mentioning it to a surgical friend of mine (yes, I have them) who got all upset that I was really talking about a compartment and not a potential space (apparently I’ve been inappropriately mixing anatomical spaces my entire career). While the definition of a compartment versus a potential space is still debated hotly among anatomy nerds (yes I called you a nerd), for an EP there’s nothing like a dramatic case to remind you that not all potential spaces (or compartments or whatever, hey will you relax please?) are created equal.The elderly and morbidly obese often have a lot more “potential” to extravasate into these spaces.

In the case pictured here, a minor fall in a small woman with abundant loose adipose tissue in her arms led to substantial blood loss before spontaneously rupturing through the skin. She arrived to the ED in class III hemorrhagic shock.

So I guess if you want to be clear about it, old people on Coumadin have a lot of “potential” to bleed copiously into what seem like rather small compartments.  Okay there, does that make you happy?  I know it does.

If you would like to review the difference between a compartment and a potential space here is a mind-numbing review for you. Anatomical spaces: a review. Newell RL. Anatomy Unit, School of Biosciences, Cardiff University, UK. Newell@cardiff.ac.uk

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Postcards from the ED

The EMBER: Here is a nice blogpost from someone who went through the experience.  Sometimes a well told patient story is better than any textbook.

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Evernote Meet Google

 

Maybe it’s a hold-over from my childhood days, but September is the month of organization.  You know, the ritual purchasing of three-ring binders, pencil holders, graph paper, all with the hope and optimism that this year things will stay organized.  Inevitably by the end of the year you’re digging around your overstuffed backpack for that piece of paper with the homework assignment on it.

Now instead of three-ring binders I hoard information online: downloading, tagging, and clipping, all in the vain hope that it will stay organized for some future use. And why not.  I spend a lot of time reading and searching online for emergency medicine information for my particular learning needs. Unfortunately, most of it collects digital dust on my hard drive or cloud – the junk drawers of the digital age.

So here is a great new tool that is actually getting me to use the information I’ve already collected.  Evernote meet Google.  Evernote now allows you to simultaneously search Google and your Evernote folder on any web browser.  Want to review subtle ECG findings suggestive of STEMI?  Type STEMI into Google and it gets you 1,700,000 hits, but now it also gives me 3 notes from my Evernote account.  Since I’ve already clipped these to my account the likelihood that they are valuable to me at the moment I want it is high.

Sure enough clicking on the Evernote icon shows me I have an article from Amal Mattu about high risk ECGs, a review of subtle STEMI patterns by Dr Smith from his ECG blog, and a link to another good online ECG education site.

Wow, my preselected information side by side with the power of Google, all at my fingertips on a web browser.  Finally, I’m ready for school (can I redo fifth grade please)?

 

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Notecards in Verse – IST3

There’s a reason that the greatest speakers of truth in our society are still the comics and the poets.  As a member of the medical profession I would like to imagine that in our own way we aspire to offer truth to our patients. Sadly, we often fall short of this high aspiration.  For example, I will be discussing the practical implications of the IST3 trial in an upcoming post, but first I have to calm down.

To the IST3 collaborative I only want to say, I understand, sometimes being able to say what you really mean is hard, and when the emperor has no clothes it’s even harder.  So this EM Notecard is for you, I’ve tried to sum up the findings of your work as concisely as I can. You should know I have found the act of distilling several thousand words of important sounding medical speak into a few lines of verse profoundly cathartic.  I can only hope is has a similar therapeutic effect for you.

For everyone else, I have bundled up the latest postings on the subject. If you click on the card above it will link you to the EM Notecards in verse Pinterest board with a link to the IST3 study for your perusal. I also suggest the wonderful summary by Ryan Radecki of EMlitofNote, the post by Amit Maini over at EDTCC, and David Newman’s discussion on SMARTEM as well as his alway erudite blog post on the subject. Then come back here for a second helping of thoughtfulness on this amazing study.

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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.


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.


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.


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