Tag Archives: Emergency Medicine

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.

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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!


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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