Tag Archives: Emergency Medicine

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?

Economist-Healthcare-Spending-Waste-Chart

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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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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A Pitbull of the marine ecosystem, or just misunderstood?

Emergency Medicine is vast. Like a New York foodie on a restaurant binge, you could eat out every night and never come close to encompassing it all.  One of the techniques I’ve learned over time to accommodate this gluttony of knowledge is to find general principles that I can apply across a wide range of clinical presentations–ones that I can fall back on say when starting work in a new geographic location with unfamiliar local disease entities.

Take my first Moray Eel bite for example.  A Hilo fisherman diving on a local reef tried to reach in and get the fish he had just speared and found an eel on the other end who latched on to his hand and caused a wound similar to the picture shown below.

Now it’s safe to say in Manhattan that this is not a common chief complaint. But hey, its trauma, and it’s an animal bite, and I do this stuff all the time right?  While the general principles of treating mammalian bites certainly gets me 90% of the way on this one, I have to say I’d never quite seen a wound like this, and the issue of marine flora did make me take pause, so I’ve decided to do a quick review of the topic.

For my Aussie friends and other coastal dwellers with a reef for a back yard this post will not be news, but I found this information fascinating, and since I will no doubt be seeing more of these injuries, now’s as good a time as any to add that extra 10% to my knowledge base.

Classic Presentation of an Eel Bite to the Hand

There isn’t a lot of high quality evidence-based literature on the management of eel bites, and much of what I did review seems reminiscent of the controversies surrounding other mammalian bites (primary closure versus no closure, antibiotic prophylaxis, etc).

Fortunately, I was able to talk with Craig Thomas, an Emergency Physician in Hawaii and author of, “All Stings Considered: First Aid and Medical Treatment of Hawaii’s Marine Injuries“, and he has provided me with some useful pearls for this post.  There are also some interesting distinctions unique to marine life, and some fun facts about eels themselves that are worth mentioning.

“Something about the usual guidebook description of Hawaiian species of moray eel “Maximum size 4.5 feet” seems to be wrong here.” – Matt Standal

First, should your eel bite victim manage to kill the creature that attacked him or her, and try to present it as payment to you, I’ve learned it’s generally not recommended to eat these types of eels due to the reef fish they feed on, and the potentially high levels of Ciguatera toxin often found in their flesh.

Some ancient romans apparently found a creative way around this issue by populating salt water pools with eels and feeding their slaves to the hungry critters (who presumably had low levels of Ciguatera toxin, or really what would be the point) and according to the roman Pliny, eels tasted best when fattened on human flesh.

Needless to say this ingenious form of reverse aquaculture is unlikely to take off in the 21st century, and while it is probably more fiction than fact, it does point out the long historical relationship humans have with these creatures, and the primordial fear they engender.  Which leads us nicely into the unique mechanism of the eel bite.

Eels have some interesting physical characteristics. First their teeth are cat-like fangs, but unlike the puncture wounds of cats, eel bites tend to have a slashed appearance as noted in the first image.  As Craig puts it, ” Nobody I’ve encountered has ever been cool enough to hold still after an eel clamps onto their hand.”

Theoretically if you could stay calm long enough, the eel (being a fish who needs to push water through its mouth past its gills) will eventually need to open its mouth to breathe.  But when a creature dating back to the Pleistocene age attacks you (as he very likely attacked your small furry ancestors who were crawling around in tidal pools looking for food) your response is definitely from that primitive part of the brain that really doesn’t give a crap about anything but getting your hand back. So unless you’re Neo and can achieve a Matrix level of calm, waiting the eel out may be almost impossible. (PS if you can verify that you’ve managed this feat then you are definitely “the one” and need to reveal yourself).

So most of the slash pattern of the wound likely comes from whipping one’s arm around until the eel is ripped off the end of your hand, and these lacerations are often deep, and are at risk for nerve, deep fascia, vascular, and tendon injuries,

The sometimes vicious appearance of these wounds has also led to the idea that marine eels are pitbull-like creatures who never let go.  Craig notes, “the canard of the “bulldog moray” that requires decapitation for removal appears to be a macho diver’s hallucination.”

Another interesting thing about eels is they have a second set of pharyngeal jaws that latches on to its prey and moves it into their stomachs.  This adaptation, straight out of a Ridley Scott movie, is designed to overcome the eel’s inability to create sufficient negative pressure with its mouth to draw in its prey, and is possibly another reason for the slashing nature of the wound as it attempts to stick your finger(s) down its throat.

The eel’s teeth can often leave themselves deeply embedded in tissue.  Fortunately they are easily visible on x-ray.

All these lacerations are contaminated and so potentially at risk from both the usual skin flora, but also marine organisms such as Vibrio species.  Wound closure is acceptable in the right circumstances, particularly for cosmetic concerns on the face, and everyone should get their lifesaving tetanus update.

Whether to give prophylactic antibiotics in these cases appears to suffer from the same poor data, referral bias, and fear-based expert opinion that land mammal bites have. A minority will develop an indolent infection that will need antibiotics, and a rare few will develop a fulminant infection.  On land, we don’t give everyone who scraps their knee or has an animal bite prophylactic antibiotics, and I don’t see any literature that adding the average marine environment to a scrap or cut warrants up front antibiotic mega-guns either.  My guess is fisherman have been getting cuts and bites daily all over the world and very few of them die of septicemia 8-24 hours later.

That being said, the ocean has plenty of bacteria, the five most notable for disease being: Aeromonas species, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Vibrio vulnificus, and Mycobacterium marinum.  I found one paper that cultured a predominance of Pseudomonas and Vibrio species from the mouths of a few captive Moray eels, and there is enough case based literature to strike fear into any litigation wary emergency physician.

Vibrio sp. appears to have the most potential for fulminant disease and septicemia, and most of the the concern for Vibrio species in wounds cites surveillance based literature for outbreaks in recreational waters, from the ingestion of Vibrio from tainted seafood (which are the majority of Vibrio cases), or wound infections related to aquaculture workers who were exposed daily to high levels of bacteria and cut themselves frequently while handling fish.

These populations seem like a poor comparison to our group of single bites in a healthy person swimming in the open ocean who then comes to the emergency department and gets good wound care.

I would tend towards antibiotic prophylaxis if the location of the marine environment was known to be  particularly dirty or contaminated beyond the average seawater, if the wound was more extensive or particularly deep, or it involved a deep puncture wound that I couldn’t irrigate adequately.  Certainly injuries that need to go to the operating room for debridement or deep hand, wrist or foot injuries are another reason for considering antibiotic prophylaxis, particularly if the wound has potential to enter the tendon sheaths or deeper planes of tissue.

An immunocompromised patient, one with haemochromatosis, diabetes, or severe liver disease might derive greater benefit from antibiotic prophylaxis, but I think overall the risk/benefit of prophylactic antibiotics is a fluid line with no clear boundary, so it deserves a full discussion with your patient given the lack of definitive evidence.

Summary

  • They may look like snakes but they’re fish, envenomations are not a big concern
  • Take radiographs to exclude teeth or other foreign bodies embedded in the wound
  • Closure is okay in the right wound, particularly if cosmesis is a concern.
  • Good irrigation and wound care is likely the most important factor to reduce infection.
  • Prophylactic antibiotics are a discussion to have with your patient, but has no good evidence for the average injury
  • Deep injuries of the hands, wrists, feet likely warrant antibiotic prophylaxis
  • Consider antibiotics in the immunocompromised (HIV, transplants,steroids, etc), diabetic, hemachromatosis, or liver disease patients.
  • If antibiotics are given it should include coverage for Vibrio sp. and Pseudomonas.
  • Finally, don’t go sticking your hands in places they don’t belong.

If anyone else out there has lots of experience with marine bites, and has some pearls on this topic or good literature to reference please send it my way.

MacKenzie State Park, Big Island, Hawaii

References

The emergency management of moray eel bites. Erickson T, Vanden Hoek TL, Kuritza A, Leiken JB. Ann Emerg Med. 1992 Feb;21(2):212-6.
Source Toxikon Consortium, Section of Clinical Toxicology, Cook County Hospital and Medical Center, Chicago, Illinois.

Moray eel attack in the tropics: a case report and review of the literature. Riordan C, Hussain M, McCann J. Wilderness Environ Med. 2004 Fall;15(3):194-7.
Department of Plastic and Reconstructive Surgery, St James’s Hospital, Dublin, Ireland. CRiordan@rcsi.ie

Goldfrank’s Toxicologic Emergencies, Ninth Edition. Lewis Nelson, Neal Lewin, Mary Ann Howland, Robert Hoffman, Lewis Goldfrank, Neal Flomenbaum. Chapter 116. pp 1629-1640. Author D. Eric Bush, July 2010

Soft tissue infections following water exposure, Larry M Baddour, MD, FIDSA, UpToDate, Literature review current through: Jun 2012. | This topic last updated: Nov 5, 2010.

Vibrio vulnificus infections, UpToDate, Author J Glenn Morris, Jr, MD, MPH&TM, Literature review current through: Jun 2012. | This topic last updated: Jun 19, 2012.

Marine bacteria complicating seawater near-drowning and marine wounds: A hypothesis, MD J.K. Sims, MICT Philip I. Enomoto, MD Richard I. Frankel, MD Livingston M.F. Wong, Annals of Emergency Medicine, Volume 12, Issue 4 , Pages 212-216, April 1983

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Tools to Live By – One Minute Ultrasound

At the dawn of the golden age of the peripheral brain, access to information seems limitless.  Need to get a stain out of a tablecloth?  No problem, Google has 500 solutions.  Your dog’s breath smells? There’s likely a Youtube video for that.  But when it comes to the busy EP, the real information challenge is not finding something online when you’re home on the couch half-watching TV, and getting in trouble with your wife by commenting on how stupid Gray’s Anatomy really is, but finding focused, readily accessible information for the busy ED context in which it’s required. Type FAST exam into Google and it still doesn’t know if you need an overview of the current literature or a quick video on what Morrison’s space is supposed to look like.

One solution is dedicated apps on your smartphone that bundle discrete information into a coherent whole.  Unfortunately some apps are just bad and even worse than just a simple Google search, some information is just not amenable to an app, and even good apps can become cumbersome if you have hundreds on your phone you have to sift through.

Ultrasound tutorials were a natural early choice for online Emergency Medicine education and readily take advantage of video, text and audio formats. But the same problem of context still exists: is that one hour lecture on ultrasound in pregnancy really appropriate when all you want to do is review definitive signs of early pregnancy before going in to see your patient?

That’s where the new One Minute Ultrasound app finds its niche.  Mike and Matt at Ultrasound Podcast.com have created a collection of short video tutorials on many of the bread and butter ultrasound exams performed by EPs daily.  This is great for the resident doing ultrasound, but still perfecting their skills, or for the older EP who wants get more comfortable with ultrasound in their daily practice.  Its also a great quick review for EPs comfortable with ultrasound but looking for a quick refresher.

The app itself has a couple of bugs, but overall it meets the major requirements of being fast and easy to access, and it’s concise, and high yield.  Pull it out of your pocket on the subway when you have a minute or two, or before going in to see a patient for a rapid review.  A great first pass, that will no doubt get better.  Best of all, since it is free and open access there is no downside to giving it a try.  Thanks to the guys from Ultrasound Podcast for adding to our toolbox.


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


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