The EMBER Project

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?

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.

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.

Design Challenge Innovators

Yesterday 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”

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.  If you are using Haiku Deck to give a talk it also re-enforces the idea the slides are only for emphasis – if you’re reading of them you’ve got too much on your slides.


So here is my latest Haiku Deck, part of a teaching module for our airway course. I was so inspired I wrote a Haiku to start things off.

Airway Haiku

The Airway is hard

How sweet the Grade One view is!

Pearls for you there are

Enjoy

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

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.


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”


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

Click to go to the educational content

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 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!

 

After two wonderful years in Hawaii, I’m returning to New York to take up new clinical and educational challenges.  Before I do, I thought it was appropriate to send one last “postcard from the ED”. This one comes from a case that reminded me that when it comes to decision rules, “there are more things in heaven and earth…than are dreamt of in your philosophy.” Here it is:

A 38 year old surfer comes into the ED by private vehicle. He was driven by a friend to get some pain medication for “spraining my neck”. After being hit by a large wave and tossed around he felt a pop and began to notice severe pain in his neck. At first he tried to paddle back out, but the pain forced him to come to the beach.  After about an hour the pain had not improved and he decided he needed some stronger pain medication.

He had no other injuries, no focal neurologic deficits, and had not been drinking. On examination he had no change in his level of consciousness, he had a normal neurologic exam.  The location of his pain was para-spinal located in the upper cervical muscles by the occiput, and he said “his throat hurt”. He was unable and unwilling to rotate his neck in any direction.

Based on NEXUS this patient could have potentially been cleared clinically.  However, having lived in Hawaii for some time, I have learned to respect the power of the ocean. For me any surf related injury is a high risk mechanism until proven otherwise. If you were not to treat this as a high-risk mechanism and were using the Canadian c-spine rule, you would have gotten to the “able to rotate neck” part before slapping that cervical collar back in place, which is what I did.  Below you can see the reformatted image of a C1 fracture. The patient was accepted for transfer to the trauma center, where he was treated and released with no neurologic deficits.

In hindsight I believe the absence of midline tenderness was due to the extreme amount of soft tissue pain he was in, and the muscular splinting of his unstable C1 fracture. To me it could have counted as a distracting injury however I’m not sure I’ve ever considered para-spinal strain as a distracting injury. Maybe it is a flaw in the language, since the word distracting means “taking your attention elsewhere”. This implies that the pain should be somewhere other than the neck.

Other than mechanism, the real red flag for me was his unwillingness to move his neck. In my experience the alert patient with an unstable c-spine fracture DOES NOT want to move!!!  I’ve also come to realize, working in rural community hospitals here in Hawaii, you paradoxically see more of the isolated serious walk in traumas than you do in a major trauma center. Often the rules of tertiary care practice do not translate. Here are some of the key take away points for me in this case.

North Shore Surfing Accident

Postcards from the Emergency Department (Hawaii)

  1. A patient with a mechanism that is unfamiliar to the physician may be overlooked as high risk due to lack of experience with that type of injury.
  2. For obvious reasons clinical decision rules in trauma are designed using a patient pool which is skewed towards common injury patterns. Unusual mechanisms or patterns of injury unique to your clinical environment (in this case surfing) should be treated as potentially outside the scope of these rules.

There has been some recent trauma literature suggesting that these rules don’t apply to trauma activation criteria patients, This was a reminder that they do not always apply to non-trauma activation patients either. We teach these clinical decision rules, but it is imperative that we also teach the inclusion and exclusion criteria used in the studies, the potential flaws in the human application of these rules, and the limitations of all studies to be generalizable to all patients, so that we can better decide if they apply to the patient in our ED at any given moment.

Finally, if you do use the rules I would consider the combination of NEXUS and Canadian algorithm.  Dr Scott Weingart has a compelling argument and a nice diagram showing how the two can work in synergy.  In this case my patient would have also failed to be cleared clinically based on the combined rule.

The EMBER is a small bundle of free open access resources to deepen your knowledge. Thanks to all the educators out there putting time and energy into teaching others.

http://emcrit.org/podcasts/cervical-spine-injuries-i/

http://www.mdcalc.com/nexus-criteria-for-c-spine-imaging/

http://hsc.unm.edu/emermed/resident_readings/EDArticles_PDF/Trauma/NEJM_03-%20CAN%20C-Spine%20v%20Nexus.pdf

http://www.ncbi.nlm.nih.gov/pubmed/21610391

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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The EMBER Project.002

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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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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