The EMBER Project

New STEMI equivalents keep showing up all the time.  What is a STEMI equivalent you ask? For those ECG nerds out there (you know who you are, yes the one’s with the calipers in my ED) it is the rapidly expanding number of ECG patterns, beyond the traditional ST elevations, that suggest an acute coronary occlusion and therefore require emergent revascularization..  Here is one I was unaware of until just recently. Add it to your list.

Photo from Dec 3, 2012

The EMBER:

Dr Smith’s ECG Blog  Back Pain Radiating to the Chest in a man in his 40’s

Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction

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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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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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.

The EMBER Project’s Education Manifesto – An Introduction

An underground handbook for surviving and thriving on your shifts as an EP

BPP - Oakland 1969

There is a knowledge gap in Emergency Medicine.  It lies within the difference between the way we teach and the way we learn.  Bridging this gap is the EMBER Project’s educational manifesto of sorts.  It starts with the belief that our continuing education as Emergency Physicians should not be an endless continuation of the traditional didactics we’ve become accustomed to in our formal training as physicians. Instead it should be a more complete and thoughtful examination of what makes us successful in our daily EM practice.

Over time we become suffused with a host of accumulated skills, knowledge, wisdom, tools, and relationships, and we develop conscious and unconscious strategies for success in the emergency department. Sadly, most of this knowledge is not recognized by us or even taught to new physicians, and falls into what I like to call the “crash and burn” school of medical education.

Perhaps because we have had to learn much of it by personal experience, we have difficulty recognizing its central importance in our development as good physicians – much less being able to describe how we became proficient in these areas to others. Teaching is a skill.  We learn by watching others.  I learned how to teach ECG interpretation by being taught by someone else, but how do you teach skills that have never been taught to you?

The second tenet of the manifesto is that physician well-being and patient care are inextricable.  Success in Emergency Medicine starts with accepting that our physical and emotional resources are finite, and that the practice of Emergency Medicine is challenging. For generations I believe that publicly acknowledging our limits and the fear that we will be seen as lazy have been conflated in our profession.  The stereotype of the tireless physician and the fall out from this impossible ideal still haunts us.

We have limits, rather than ignore them, we must learn to minimize the impact  of those things which are a drain on us, and maximize the supportive resources we have around us.  Doing this well is part of becoming an efficient practitioner of the EM art, and is essential to longevity and well-being in our profession.

The Smooth Sailing series takes both of these concepts to heart.  It is a re-examination of our development as Emergency Physicians from a personal well-being perspective, in order to define the strategies that help us develop a sustainable career of continued growth, improve how we care for our patients, and getting you home at the end of hard shifts happy and healthy.

I’m excited to begin exploring what makes us successful and healthy emergency physicians in this series.  I hope you find it as useful and interesting as I do, and that you will share your insights and comments with me along the way.  Perhaps in discussing how we acquire these skills they will become part of a more conscious strategy for success that we will be able to pass on and teach to others.  Stay tuned, the first chapter in this series is coming very soon.  In the meantime please check out the last Smooth Sailing post to get an idea of where we’re headed.

The Rules of the Road

One of the things I’ve learned in Emergency Medicine is that if we don’t define ourselves then others will be more than willing to do it for us. The struggle to set the driving principles and priorities of our profession occurs in a thousand places; in a thousand different ways every day, and all of us are acutely aware how these struggles can impact the quality of our practice. That’s why it’s so disconcerting to see a trend within our speciality that potentially undermines us as clinicians.

In the current issue of Annals of Emergency Medicine, Dr. Schriger and Dr. Newman have teamed up to write about risk stratification tools.  Their motivation for the piece is in response to a concomitant publication about a potential biomarker for defining low risk head trauma, and the possibility that it could reduce the number of head CTs we order in these patients.  Here are the key points of their article.

  • There has been a huge proliferation in clinical decision tools that attempt to define low risk patients in the Emergency Department.
  • Many of these tools are poorly designed, and based on false assumptions about physician judgement, subjectivity, and why tests are ordered.
  • The overall benefit of these tools is questionable without a properly defined, clinically relevant method of evaluating them against physician evaluation alone.

The article is a call to reform our methodology but it’s also a plea to address some of our deeper assumptions before we run ourselves off a cliff with decision tool driven testing. The flawed assumption goes something like this:  clinical judgement is subjective and therefore imperfect.  The answer then is to find another more objective tool to save us from ourselves.

This strange desire to want simple answers for complex problems belies the fact that all tests are flawed, and that subjectivity is itself a tool that can be tested like any other.  It also ignores the fact that in the face of complexity sometimes there is no better tool than subjectivity.  It is a finely tuned  instrument developed over millions of years to absorb data and make quick and successful decisions in the face of rapidly changing information. Combine this with years of training and experience and it becomes a powerful foundation for most of what we call the practice of medicine.

Praising subjectivity is not a nostalgic plea for a return to the days when a doctor had only their experience and clinical exam skills to inform medical decision-making (these too are just imperfect tools) nor is it antithetical to the practice of best evidence. It’s simply a request not to “systematically discount”  doctors clinical ability in the name of progress, or burden us with expensive, cumbersome, or difficult to remember rules when clinical gestalt might work just as well – if not better.

Subjectivity, as Dr. Schriger and Dr. Newman elegantly point out, is inextricable from the process of medical decision making, and attempting to build an intellectual bypass around it with decision tools is a road to nowhere.

References:

Medical decision-making: Let’s Not Forget the Physician, David L. Schriger, MD, MPH, David H. Newman, MD. From the University of California, Los Angeles, Los Angeles, CA (Schriger); and the Mt. Sinai School of Medicine, New York, NY (Newman).


RUSH – Excelling at the Bedside

One of the areas that Emergency Medicine excels in is the rapid assessment of patients at the bedside, and as such it makes sense that we should be leaders in innovations that help bring this skill to its apogee. In an upcoming post I will talk about this more, but for now suffice it to say that it is one of the reasons I love ultrasound, and in particular the RUSH (Rapid Ultrasound for Shock and Hypotension) exam as an example of what we should be striving for.  I’ve just spent the afternoon reading:

The RUSH Exam 2012: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill Patient, by Phillips Perera, MD, RDMS, Thomas Mailhot, MD, RDMSa, David Riley, MD, MS, RDMS, Diku Mandavia, MD, FRCPC  The RUSH Exam 2012.  The RUSH Exam 2012 (annotated version)

For those not familiar with RUSH, it is the FAST (Focused Assessment with Sonography for Trauma) exam, along with other familiar cardiovascular ultrasound techniques, to rapidly assess the patient in undifferentiated shock.  But this simple explanation belies its true genius: by applying concepts in physiology, with bedside clinical acumen within a structured collection of ultrasound imaging techniques, a powerful diagnostic tool emerges. I’m a big fan of this innovation, and hope we will see more of this creativity in the future of our specialty.

The above article is a bit long, so I’ve annotated and highlighted a copy of it to emphasize what I think are the most relevant parts for a practicing EM physician who already has decent ultrasound ability. I’m also bundling a few other resources on the topic so that you can really get familiar with the exam.  In my experience you have to reach a certain comfort level with a technique before it can become a part of your daily practice.  After that its smooth sailing.  ENJOY.

  • Sinai Emergency Medicine Ultrasound @http://sinaiem.us/   This site has a bunch of great tutorials on all the aspects of the exam.
  • I am not familiar with the detailed evolution of the RUSH exam in its current form, but Scott Weingart MD over at EMCrit.org has been a leader in this area for nearly a decade now and his site has a great overview as well as an audio lecture on the topic that is well worth listening to.
  • All LA Conference lecture on “Undifferentiated Hypotension” by Ravi Morchi MD.  This is a great lecture that pulls together all of the physiology concepts involved in the RUSH exam to bring it all home for you.

Hot off the Press

Walter Winchell, New York. 1950s.

I used to love all those “myths in medicine lectures” as a resident.  For a while I collected evidence-based Myth-buster articles like trophies, and to me the truth hunters who unearthed and dispelled these myths were heroic dragons slayers, but it turns out that the dragon is really a many-headed hydra, and I just can’t keep track of how many things I’ve been taught as absolute gospel that have in fact turned out to have no basis in reality whatsoever.

Honestly I’m starting to believe that doctors have a special affinity for believing their own bullshit that is unparalleled in any profession.  Wait, can you say Newt Gingrich?  Okay, maybe we’re not so bad.  Despite my irrational desire to join the republican party and hum along with Mitt that poor people are just fine, I present to you this Myth-busters article that caught my attention after being posted by the folks over at EDTCC:

Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma Inaba, Kenji MD; Lustenberger, Thomas MD; Recinos, Gustavo MD; Georgiou, Crysanthos MD; Velmahos, George C. MD; Brown, Carlos VR; Salim, Ali MD; Demetriades, Demetrios MD; Rhee, Peter MD

In this study there was no difference in any of the clinical outcomes they measured between large and small chest tubes in trauma.  So how long have I been pushing 40F tubes into patients for no good reason? I once put a 28F into a little old lady with a large hemothorax (who probably weighed 90lbs wet) because I couldn’t even get my pinky finger past her ribs, and then I never heard the end of it from the trauma service.

While the study found no difference in pain between the small and large size chest tube groups, at least now I can make a choice based on my patient rather than tube size. Thanks Kenji & Co. for lopping off another head.  (and nice job on the title).

EM Walkabout – Smooth Sailing in the ED

Western Coast of Australia Near Broome

In honor of the first EM walkabout, I thought it was only fitting to start with an inspired article from the BroomeDocs.  Some of the greatest “thank-you” moments I have had exploring online EM education comes from people sharing bits about how they practice the daily art of caring for patients. Maybe it’s a validation of something you have done unconsciously for years, but never had it pointed out to you, maybe it is the relief of knowing others struggle with the same issues, maybe it is a moment of clarity on a topic that never quite solidified until now.

Whatever its origin, the momentary sense of community, clarity, and gratefulness is without equal in education. I happened to have one of those moments with this post by Casey Parker. Consult Skills 2: When Agendas Collide or “Physician Know Thyself”.  This post on dealing with the patient who may have a radically different agenda than yours got me thinking about how I interact and share with patients, and how the subtle tone of that has changed over the years for the better, making the number of good days in the ED far outweigh the bad ones for me.

Surviving a 12 hour shift in the ED is all about charting your course for smooth sailing.  From the moment you start taking sign-out, to the last patient you see 15 minutes before your shift ends, I have learned the hard way that confrontation sets you up for failure.  Now I’m not saying you don’t drop the hammer when you need to, or stand your ground when you feel it is in the best interest of patient care, but if you do it the wrong way, even if you win you lose.

Whether you walk out of your shift emotionally drained looking for a quiet place to curl up in a fetal position, or come home happy and sane with the energy to go for a run with your dog all depends upon the subtle ways you learn to interact with your patients, colleagues, consults, lab techs, and everyone else essential to your daily practice.  So this EM walkabout will be dedicated to all those moments when I learned something about how to find smooth sailing during my shifts in the ED.  Thanks Dr Casey Parker for giving us a great starting point.

Smooth Sailing off the coast of Western Australia

Who can do this job without some kind of liquid encouragement.  Sure, I used to drink the 75 cent coffee from the truck outside the ED at Columbia on 168th street to keep me going, but what started as a mundane necessity is now more of a daily epiphany.  The shot below was taken after a particularly long overnight at one of my neighborhood hangouts, where I ran into another EM doc just heading to work (show me a good place to get coffee and I’ll guarantee you there’s an EM doc standing in line before his shift to drink it).  Now, I know all you EM coffee geeks are just waiting to get your Restretto on, so please consider sending me photos of you, your coffee, and the places you enjoy it, and I will keep posting coffee porn.  I want a gallery of EM docs with their coffee…

Post Overnight Coffee @ Peels, East Village NYC

Tools to Learn by – Google Reader

So this post is for those of you who have yet to fully take the plunge into the new information stream. Sure you can find your way around a web browser and search google, but do you know what a blog aggregator is? Now let me say that I am just an ordinary emergency physician who loves what the marriage of my iPad and online educational content has done to my level of daily learning. My daily explorations into the educational uses of  technology have made me designated CIO of our household when the WIFI isn’t working, but I AM NOT, spending my free time debugging source code or longing to be Neo in the Matrix. My goal is really to explore and learn what is available to me online and find ways of using it and sharing it. Opinions here are really based only on my own personal experience of what seems to have worked best over time.

Things online have changed in the last few years. Sure audio, video and written content were out there for you if you wanted to learn, but it was not always easy to find, and you had to go looking for it. Much of the good stuff was locked behind paid content subscription walls, relics of the old ivory tower. Not only that, but you had to go to your computer, navigate to the site, enter your id and password, and then if you ever wanted to bookmark or save your favorite content for future use well, forget about it. If you were lucky you got an email letting you know about new content, but mostly they got hold of you when your subscription was about to run out. Today the landscape has become dramatically more education friendly for two reasons: blogs and aggregators.

First the proliferation and ease of use of blogs and online sites have made it easier and easier to offer regular, high quality educational content online. Second, and equally important is that rather than sitting there waiting for you to retrieve it, this content can come to you. In fact a whole industry has grown up online for this purpose. Tools such as RSS feeds, and social media sites (coupled with smartphones and tablets), make the options for customizing and creating a personal education universe nothing short of revolutionary.

With this kind of unbounded information it is a bit like trying to capture dark matter whizzing by with a butterfly net. Information is not necessarily education. The goal, as I have come to appreciate, is learning to capture content out of that stream with as much ease and sophistication as is necessary for your needs. There are so many tools that it is impossible to list them all, but think of each as simply a way to capture information that is of value to you while filtering out the information that has little or no value. These aggregators of information come in various forms, and later I will post about different ones that may appeal to you depending on your learning style, but for those who want to follow this blog and explore a little bit beyond, here are the big three as I see them.

Google Reader is the king of all aggregators, if you don’t have a google account, you need one (okay seriously if you really don’t have one, stop what your doing and go sign up… I’ll wait). While google offers some amazing online tools, one of the most powerful from an education perspective is Google Reader. Just put in the web address or url of a blog you want to follow and presto you are treated to all its content in one place. Now multiply that by an infinite number and organize them into topics and you get the idea. Google reader will even suggest new bundles of content related to the site you just subscribed to a site. As you can see from the screenshot below you can quickly amass a long list of EM blogs so I suggest putting them all in one folder. Its like having the Emergency Medicine Times delivered to your door everyday. Over time you will edit out the ones with content you never read, and prioritize the ones you do.  On my blogroll is a list of my favorite EM education sites to get you started.

The big issue with Google reader is that while it is a great aggregator it is not visually appealing. Sure you may laugh at the idea that aesthetics and visual page layout are important if you want to learn, but let’s face it do you want to read your content like this:

Or this:

There’s a reason a big beautiful National Geographic style cover pic with cool typeface gets lingered over while a webpage cluttered with ads and unreadable font gets quickly deleted. Bottom line you want to love what you read.  Don’t worry, this doesn’t matter in the end because you can think of Google reader as just your organization drawer for EM content. If you love it you can stick with it (it has gotten better over the last few months) or link it to a number of other readers that will make your content mobile, easy to browse, and beautiful. In upcoming posts I will show you how to make picking up your and iPad, and seeing what you are going to learn about today a true pleasure.

Up next. Facebook and Twitter as EM education tools.

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