The EMBER Project

Resuscitate before you intubate!

Part of the Protected Airway Series

Your in the driver’s seat, cruising down the fast lane towards your next intubation in the Emergency Department. But before you take your next patient along for the ride, you should ask yourself if your driving in the HOV lane.

It’s important to remember that we don’t intubate healthy people for elective procedures in the Emergency Department. When a definitive airway is needed we intervene because the physiology of our sick patient is requiring us to act to protect them from further harm.

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But the intersection of critically ill physiology and endotracheal intubation is a dangerous one: we can quickly turn a problem into a disaster if we focus only on the mechanics of the procedure, and fail to prepare for the effects this will have on our sick patients.

Fortunately, a little knowledge and planning can help you navigate this intersection between dangerous physiology and endotracheal intubation by understanding how they combine to cause harm. One way to do this is to ask yourself, “is my patient in the HOV lane?”

The HOV mnemonic — Hypotension, Oxygenation, Ventilation (pH) is a simple way to organize some of the key concepts and clinical skills required for protecting your sick patients during the dangerous peri-intubation period. Here it is:

The full presentation with notes is available on HAIKUDECK.

The EMBER  – Curated FOAM content all bundled in one place

For deeper cuts on this topic there is no better source than Dr Scott Weingart’s “Laryngoscope as a Murder Weapon” series.  The most comprehensive, innovative and valuable series of lectures on this topic I know of.


EMCrit – Laryngoscope as a Murder Weapon (LAMW) Series – By Scott Weingart.

Download, bookmark, aggregate, follow & create for a happy new year!

The holidays are over and with it 2015 is coming to a close. One of the missions of the EMBER Project is to help you organize your flow of information so that it’s relevant and accessible when you need it. Here are four skills and some tools we’ve come across in 2015 that will help you learn, teach, and grow as a physician and an educator.



screen568x568ACEP Toxicology Section Antidote App – By American College of Emergency Physicians.

Some information can be stored in the cloud or your hard-drive for leisurely review. When taking care of your critically ill patients there is some information that can’t be left to a Google search. Mobile apps are still useful when you want critical information at your fingertips that is easy to access and trustworthy. The ACEP Antidote app is one of those. and will be on my iPhone in 2016.



dded87_3069f29a335c688a8b97789585bc1d89Critical Appraisal Skills Programme (CASP) – Making sense of evidence. 

Industry funded research, profit motive and competing interests that don’t always align with patient or public health interests make critical appraisal of the medical literature  a top priority The developers of this site from Oxford have developed workshops and tools for learning how to critically appraise medical research.


icontexto-inside-twitterI use Twitter as my tool to network and to organize the flow of EM relevant news, research, opinion and just plain interesting voices.  Here are a couple of the breakout voices I’ve been following in 2015 and will be watching for in 2016

@AirwayNauts By Jim DuCanto & Friends.

Those involved in the solemn deliberate study and practice of navigating, sailing, exploring, and innovating airway management are known as “AirwayNatics”.

@brennafarmer1 One of my smartest friends; wears more hats well than anyone I know.

Medication Safety, Patient Safety, Emergency Medicine, Toxicology expert.

@jameshorowitzmd  Jim is my go to guy for advanced VTE care in sick patients. I expect many great insights from him in 2016

Cardiac Critical Care. Co-Director Pulmonary Embolism Advanced Care team 

If you want to see the complete list of who I follow on Twitter in Emergency Medicine here it is. Feel free to pick and choose for a great stream of information. Then add it to one of the apps below!


News aggregators like Feedly help you collect, follow and share the many streams of information into one place, and are your lifeline for keeping track of it all.  Here are the one’s I liked most in 2015 and will continue to use in 2016.

flipboardNYCFlipboard aggregates articles, video, podcasts, and social media into a beautiful and mobile, print-style digital magazine. With it’s browser widget and other tools it makes collecting and sharing news  easy. In addition it allows you to create and curate your own magazines with multiple editors if you.  By far my favorite aggregator.

pocket-appThe one thing Flipboard doesn’t do is allow for collecting for offline reading. For this I use Pocket. A great tool if what you are looking to do is “clip” an article, video, or other content for later.




311605691_640In 2015 I hosted an innovation in medical education Design Challenge where I encouraged our residents and many of my expert colleagues to free their lectures from their hard-drives, and find easy and creative ways to translate their knowledge from powerpoint slides into more accessible and visually appealing alternatives.

One of my favorite tools of 2015 was Haiku Deck, it’s a wonderful alternative to Powerpoint.  Here are a few decks I made in 2015. I’m sure I’ll be making more in 2016.


That’s it for us at the EMBER Project this year. Happy New Year!!


Have you noticed a change in your airway box recently?  No, it’s not the new McGrath or C-MAC or any other cool high-tech tool. It’s a more subtle change.

It used to be when you prepared for a sick patient to arrive that you opened up the box, grabbed a handle, and slapped on your go to metal blade to check the bulb before the patient arrived. If that patient didn’t need intubation the blade went back in the box.

Not anymore. Emerging concerns about cross-contamination  and increased scrutiny by regulatory groups has led to some changes in equipment and also a need for changes in practice. Blades need to be appropriately cleaned, sterilized and sealed; once opened they can’t be put back.

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The problem is that the traditional metal blades often had light issues related to multiple use and sterilization techniques – hence the habit all Emergency Physicians have of checking the blade prior to the arrival of a sick patient.

At my institution, the solution has been new disposable blades that are sealed and packaged (and look a lot like the old reusable metal blades) which is why the old habit is hard to break. These disposable blades rarely have bulb issues and there is more than one blade available if you happen to run across a broken one. We also added a non-sterile (not for patient use) blade to check the handle battery function.

So resist the urge to open that packaged blade and check the bulb, because now you can’t put it back in the box. Well, you can but you’ll just be asking for a JAHCO citation.

The Bundle – Clinical resources you can use

Five Things The Joint Commission Thinks You Should Know About Laryngoscopes and Endotracheal Tubes by Linda Hertzberg, M.D.

Maintaining your learning stream (your customized flow of educational content) is a key part of being an  effective lifelong learner. Even in the age of FOAM the center of your learning network can become heavily weighted towards just a few resources; which is why taking the time to search periodically for new ones should be as routine as cleaning your hard drive.

Content sources within the FOAM universe are of course easier to find, but this can become a self-referential system, and so I try to spend time periodically looking for relevant but unusual places with new learning.  The Autopsy Center of Chicago blog is one of those.

Autopsy rates have declined dramatically in recent decades, and the valuable feedback they provide for clinicians has declined with them. According to the CDC, overall autopsy rates have dropped more than 50 percent since 1972. That number gets worse if you look just at autopsies performed for disease related deaths.

While autopsy rates may be declining, in a hashtag world, the potential knowledge to be gained from them doesn’t have to. The Autopsy Center of Chicago has a blog that presents interesting monthly cases, and offers a view into the pathologist’s post hoc world I find fascinating and educational. Sure, it’s not like getting autopsy results on your patient, but there is still plenty of educational value for clinicians here. It also has some unexpected features, such as insight into family motivations for wanting an autopsy, and the emotional value they contain.

Aortic rupture presenting as hip pain

Looking at this site makes me wonder why there isn’t a national autopsy registry with regular updates for clinicians on what is being discovered about the diseases we treat, mistreat, or just miss all together. In the meantime, I’m adding this blog to my favorite Flipboard feed.

Sorry, I couldn’t resist the urge to throw in some 70’s medical television on this one.




Are They a Good Choice?

By – Lucy Willis MD

Low back pain is an extremely common ED complaint, for which opiates are frequently prescribed. The last 20 years has seen the development of an opioid overdose epidemic. The rate of death from prescription opioids has increased fourfold and is now higher than heroin and cocaine combined.overdoseeveryday-450w

As emergency physicians, we are are always weighing risk/benefit ratios when making treatment decisions, and this is now a complex task when it comes to treating pain. There is a lack of literature demonstrating the effectiveness of opiates for the treatment of low back pain. ( See ACEP clinical policy on Opioids).

For our first NYP LM Journal Club, we are reviewing the recent JAMA study, Naproxen With Cyclobenzaprine, Oxycodone/APAP, or Placebo for Treating Acute Low Back Pain. This was a randomized, double blind, 3 group study carried out in an urban ED in the Bronx. Patients with nonradicular acute low back pain were randomized to either naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/APAP.

The primary outcome was an improvement in functional outcome at 1 week. There was no difference between the 3 groups! However, there was a trend toward benefit in the oxycodone/APAP group as they were more likely to report pain levels of mild or none, with a NNT of 6. However, if you balance this against the NNT of 5 for adverse effects (drowsiness, dizziness, stomach irritation, n/v) and the potential for abuse, the authors of the study conclude that their study does not support the addition of these medication to NSAIDs in this setting.


#Postards from the ED

There are educational courses and there are inspirational courses. I had the opportunity this weekend to participate at BASE Camp. The brainchild of Kevin Ching, it’s an amazing and unique two days of education.

For those of you who don’t know about this great opportunity, it is, as the website says:

a high-intensity, fully immersive weekend of simulated pediatric emergencies where fellows and nurses work together in multidisciplinary teams to manage critically ill and injured children and adolescents

BASE Camp certainly lives up to this, but perhaps the best aspect of the course is the amazing feedback participants get after each case.  By the end of the second day it was moving to see the sense of common purpose and renewed enthusiasm for what we do every day that was clearly visible in all the participants. As I said, there are educational courses and then there are inspirational ones.  This one is definitely both…


#Postcard from the ED

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

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