The EMBER Project

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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Aloha

A post here has been long overdue.  For those of you who know me, the month of July has been my transition from a busy urban medical center in New York to a busy rural ED on the Big Island of Hawaii.  My new colleagues are wonderful, and the nursing staff is great (the first time I went in to repair a lac and found the wound already irrigated, prepped, with the suture tray completely set up I nearly fell over).

The most notable change is of course the acceptable attire for a day in the emergency department.  Amongst the things I’ve discovered in my first month is that the pattern on Aloha shirts can actually hide a great deal, Moray Eels are not to be trifled with, Wana (pronounced Vana) is painful, and waiting on the air rescue team during inclement weather while you watch over your deteriorating STEMI patient is anxiety provoking. Some of this will be part of the upcoming educational posts I have planned for August.

Aloha. The Ember Project moves to Hawaii

One of the traits that drew me to Emergency Medicine as a specialty is the resilience and creativity of its practitioners in the face of an endless array of unexpected and challenging clinical situations.  Nothing epitomizes this more than the rural emergency physician.  I’m already very impressed, and looking forward to growing as an EM doc in my new home.

Happy Independence Day

The Devil is in the Details

If you look to the right on this blog you will notice that I recently retweeted a great pearl from the Critical Care guys (@critcareguys) about hanging the Zosyn before the Vancomycin in severe sepsis patients.  They remind us that Zosyn has a broader antimicrobial spectrum and goes in faster, potentially offering greater benefit to your sick patient.

This has always been my practice, but I can’t tell you how many times early on in my career I found the Vancomycin hanging first. This used to drive me crazy, until I figured out what was going on. As it turns out this seemingly simple tenant of good care is one of those “devil is in the details” problems that no one tells you about.

Vancomycin is pre-mixed and quickly available in most EDs.  Zosyn is also readily available, but has to be reconstituted, which as any nurse will tell you is a pain in the ass.  Now in the age of EMRs the orders for the Vancomycin and Zosyn are placed together and no face to face communication happens with the nurse.  Now they’re busy too.  They see the antibiotic orders, grab the Vancomycin because it’s premixed, and they have 15 other orders to take care of.  That gives them an hour before they have to shake and bake the Zosyn.  Ta dah! Now you walk into the patient’s room 45 minutes later to see your septic patient with the slow drip of vitamin V instead of Z.

I have a method for dealing with this problem (it’s number 2), but it becomes an issue again if you work with residents or mid-level providers when I ask the dreaded question, “did patient x get the Zosyn?” And the all too common answer comes back “yes, I ordered it”  (which actually means no, or I don’t know to me until proven otherwise).  So unless you know your resident or PA, make sure they know what you want and what they have to do to make it happen.

So there you have it.  I have tried all three of the methods below to make sure the Zosyn goes in first.  Anybody else have a method?

1.  Put the Zosyn order in first,wait 20 minutes, and then put in the Vancomycin order. (Time consuming, inefficient, and not guaranteed to work)

2. Just talk to your nurse and tell them what you want first and why. (your best bet, and it fosters communication..if you like that sort of thing)

3. Hide the Vancomycin until the Zosyn is hung. (just childish)

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Lessons From One Hot Joint

One thing I love about Emergency Medicine is that no two cases of the same disease are ever exactly alike.  Yes this can be anxiety provoking, but I prefer to think of it as akin to great jazz tunes – it nostalgically reminds you of other versions of a song you’ve heard before, but the players and the riffs are distinctly unique.

A case in point, the hot joint has presented some interesting challenges to me on a number of cases.  Most recently, a thirty something intravenous drug user with several days of increasing pain, redness, swelling of her left shoulder appeared for all the world to be a septic joint.  She had a great history, classic presentation, and initial labs showed and white count, ESR, and CRP through the roof.  Now I love doing taps, but in our ED we involve orthopedics for many of them, particularly the shoulders.  The talented orthopedic resident to my surprise was not interested in tapping it.

My initial response to him was that no matter what you tell me the pretest probability that this IV drug user has a septic joint is so high, no test other than an arthrocentesis is going to satisfy me.  But the orthopedic resident had some interesting and valid concerns, and the more I thought about it the more I recognized that there were some interesting clues along the way that led away from a septic joint:

1. The pain began after direct inoculation with a needle into the shoulder (rather than by hematogenous spread of bacteria to the joint from an intravenous needle) so it seemed unlikely to me that the patient had jammed a needle all the way into her glenohumeral joint.

2. The patient really didn’t want to move the shoulder at all, and was guarding it gingerly, but in fact with gentle passive range of motion there was a few degrees of flexion and extension, in contrast the patient did not want to abduct at all, offering the possibility of an infected subacromial bursitis

The orthopedic resident was concerned that putting a needle into the joint through an infected abscess or bursitis would potentially seed a sterile joint with bacteria and make things worse, so we agreed on a quick initial ultrasound. This was read by radiology as a septic joint, with increased joint space fluid and surrounding reactive hyper-vascularity.

At this point we tapped the joint.  Our posterior approach was a dry tap.  Frustrating as this was, it was clear we were in the joint space, but there was nothing.

So what now.  If this was a deltoid abscess, having orthopedics open up the joint would be a mistake.  An MRI would have been nice but she actually had an old needles embedded in her shoulder from prior injections so that made radiology put their foot down on that one…

So a CT of the shoulder was done which again was read as a septic joint with fluid around the joint space.  Remarkably the joint space itself was well-preserved on my read of the CT, which seemed odd to me.  My only thought at the time was that the direct inoculation of the joint had made a tract anteriorly through which the pus was draining and surrounding the joint capsule externally.

Ultimately orthopedics took her to the OR.  There they found a septic bursitis that had ruptured anteriorly and surrounded the joint capsule with pus and fluid.  The integrity of the joint itself was well maintained.  Ultimately, the patient did very well and went home several days after admission on antibiotics.

The take home points for me.

  • Think about abscess or infected bursitis before sticking a needle into a joint.  You could make things worse if you plunge a needle through infected tissue into a sterile joint space.
  • Any inflammatory markers in this situation are utterly useless.
  • Imaging can be falsely positive and may again lead to attempted arthrocentesis.
  • Complex infections around a joint are still best served on orthopedics.  There was some discussion about general surgery involvement for abscess drainage, but given the high likelihood of joint involvement in an equivocal case like this orthopedics is better equipped to debride and wash out around joint structures.

Until recently most of my thinking about red-hot and swollen joints are “what fun I get to tap it” and second I think, “when do I get to tap it”.  This general teaching holds true for most cases, but I have recently been humbled by missed taps, indeterminate taps which turn out to be infectious not inflammatory, and the reverse, cases that got unnecessary wash-outs.  So my belief that the hot joint is the last bastion of simple diagnostic procedures in the ED has been finally crushed.  There you are, you either love jazz or you don’t…

Daily Cup – The Set-up

Have I mentioned that coffee is an key player in my life as an EP?  In theory making coffee is a simple process that has only a few essential steps; yet it’s amazing how many ways you can make coffee badly, (and there is no end to the number of companies willing to sell you their way of making it badly.

Another major problem is cost.  It’s easy to spend $10 a day on good coffee which can add up.  Now I have no problem paying $3.50 for a good hit of Counter Culture espresso from time to time, but I really don’t feel compelled to dish out $20,000 for my own La Marzocco espresso machine (until I can afford to hire the barista to go with it of course).  So for around $120 I think I have found the sweet spot for home coffee production that will satisfy the needs of all the serious coffee drinkers and sleep deprived EPs out everywhere.

Step one.  The grind.  Anyone who makes good coffee will tell you the grind is key.  Screw it up with a cheap electric blade grinder or buy the coffee ground and, well, you’re on your own.  Enter the burr grinder that doesn’t cost a lot and takes the ritual of coffee making old school.  The Hario Skerton Hand Coffee Grinder – Ceramic Burr Coffee Mill.

This hand grinder does require a bit of time and elbow grease, but not excessively so.  I use the time grinding to review the dosing of my important RSI medications or the entry criteria for the Canadian C-Spine rule.

Step two. The brew.  I’m a fan of the French press.  In general they make a rich, strong brew with a taste as close to espresso as you can get without the steam.

The drawbacks are a lot of them are made of glass and don’t travel so well, and most of the plungers that filter the coffee leave a substantial amount of grounds in the bottom of your glass.

Like good wine, I don’t mind a bit of silt at the bottom of my glass, in fact I kind of enjoy it, but when I start spitting out coffee grounds like its tobacco there’s a problem.

My Espro at home with some new Stumptown coffee beans.

The Espro Press 8 Oz Stainless Steel Coffee Brewer.  Light, durable, with an insulated container to keep the coffee hot and a filter system that makes clean, grounds-free coffee.  Both of these items can be found on Amazon (I’ve provided the links).

The only downside I can see for this system is that it requires a little bit of time.  From grind to pour is about 10-15 minutes.  But that’s nothing if you consider the time it takes going out for coffee.  Once you realize that you will save a fortune in store bought coffee drinks, and be able to make it how you like every time, you may even begin to enjoy the ritual of the home brewed coffee before a shift.

ACS – More Note Cards in Verse

Surprisingly, EM Notecards in verse are a huge success (or at least they are a novelty of sorts in the EM blogosphere). Occasionally on sign-out after a long shift I will threaten the residents with having to present in Haiku if they don’t keep their sign out on point, so there is a precedent. I will say that having to distill a medical article into four lines of verse is not as hard as you might think, which makes me more convinced than ever that professional medical writing is too wordy, and just bad plain bad.

One of the most common problems is the mistaken belief that more words make you sound smarter.  How many times have you read a journal abstract and realized that the article could have been summarized clearly in one sentence (instead of the long run-on paragraph filled with medical techno-babble you were unfortunately subjected to).

I know plenty of medical literature citing patient hand-offs as the source of medical errors, but none of these, to my knowledge, have looked at the length or format of the presentation being an issue.  In my experience a dull, disorganized narrative with the important points buried in irrelevant prose makes the mind go numb.

So this note card in verse is inspired by a study that was reviewed by Dr. Radecki, over at Emergency Medicine Literature of Note.  I really love this site.  For a busy EP, having an online source that curates and critiques current articles rather than slogging through the general detritus is a good thing.  In addition he writes well, and can sum up the essence of a study in a few hundred words.  So if for some bizarre reason you want more cogent reviews of the current literature  than four lines of iambic pentameter, I encourage you to add EM Lit of Note to your blog feed.

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.

Notecards In Verse

More emergency medicine literature in verse, inspired by a new Remington-style typewriter app on my iPhone.  The clinical pearl, along with the reference literature can be found by clicking on the card.

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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