BoringEM Research Week | Guess Who? Canadian EM Research Edition

Editor’s note: This is the first in the BoringEM Research Week series. We had the wonderful fortune of hearing from some of Canadian Emergency Medicine research heroes. Of course, there are many more Canadian EM researchers than included in this post but thanks to all those who responded! You answered some serious, but mostly fun, questions about various paths in research. The candid answers should be inspiring to prospective, early and seasoned researchers alike! We hope you enjoy this of the nostalgic childhood game “Guess Who? Canadian EM Research Edition”

The 11 Canadian EM researchers who responded to the survey (and who are the answers to the below questions) are:

1. Which researcher’s very first project was the Ottawa Ankle Rules?

Dr. Ian Stiell

That’s right! Believe it or not, Ian Stiell’s first research project was the Ottawa Ankle Rules in 1990 as a part of his Master’s thesis- a TSN turning point in emergency medicine practice and research.

Don’t worry, some people are born research heroes but other become them. Your first study doesn’t have to be a blockbuster like Dr. Stiell’s but Andrew Worster suggests that to be successful you must:

“Find something that you’re passionate about. You need to be in love with your project and believe in it when you’re too tired to go on or others are telling you to give up. If you find something that you’re really passionate about, you’ll want to learn everything about it and try to answer the questions that no one else has managed to. Before you know it, you’ll be an expert on the topic.”

2. How many of the researchers think “The Question” is the most important part of the research process? 

6/11 (95% CI: 4-7)

3. Which researcher had fun studying the utility of gastric lavage for acetaminophen?

Rob Green enjoyed how hands on this research project was! He also was surprised by how many grad

Dr. Rob Green

students were willing to sign up for the study. Dr. Green reflected that if he could work with any scientist dead or alive he would choose Peter Safar, the grandfather of critical care.

4. Which researcher lived in Malawi for a year? 

Michael Schull led a cluster-randomized trial of  a healthcare worker training intervention to integrate HIV/AIDs testing, diagnosis and treatment in primary care. He loved travelling to many remote health centers and meeting inspiring health are workers doing their best to help their communities. Now, Dr. Schull uses

Dr. Michael Schull

this same energy and passion to improve care in Canada. Most of his research focuses on health service utilization, quality of care and finding solutions to emergency medicines biggest systems-based issues.

Dr. Schull is not the only Canadian EM research hero tackling systems-based issues. Andrew McRae finds that the most exciting study he has worked on is his current project. He is working to identify the 5 or 6 measures of ED crowding that have strong associations with important patient outcomes and can be measured in real-time in any ED. It’s a project that involves collaboration with a lot of people with lots of smart people! He reports that he is “learning a lot” and is excited about the project’s potential to shape ED crowding policy.

5. Which Canadian EM research hero has a background in neurophysiology?

Dr. Andrew Worster

Andrew Worster is nerdy in the best possible way. During his undergrad years he worked with a neurophysiology professor and “found everything about the process exciting!”. His FIRST Master’s thesis was on neural signal processing. He had to design the experiment and then design and build the recording equipment. He says, “the learning curve was very steep but I felt like a real scientist.” Dr. Worster’s passion for evidence-based medicine explains why, if he had the choice of absolutely anyone, he would choose to collaborate with Archie Cochrane.

6. Which researcher was on the medical team for a Rolling Stones concert? 

Dr. Russel MacDonald

Dr. Russell MacDonald helped with contingency planning for the rock concert during the SARS epidemic!!! He evaluated the processes and turned it into several peer-reviewed publications. Read one here. He is a model for making work you are doing “count twice” and this attitude fits with his ideal collaborator Thomas Edison’s sentiment “There are no rules around here- we are trying to accomplish something”. Dr. MacDonald prefers to be involved in operational research because “it examines and impacts entire health care system, not just a small segment of a population within the health care system.”

You too could combine emergency medicine research with something as awesome as rock music.

Passion + Research Skills = ENDLESS POSSIBILITIES

7. Which researcher treated a young man who returned multiple times with intentional injuries as a resident- an experience that lead to a couple of small projects, then a masters degree and an entire clinician-scientist career?

Dr. Carolyn Snider

questioned why she didn’t have the tools yet to counsel this young person who had been injured by violence and  found few answers when she tried to find out how she could help. She didn’t like the lack of answers to her questions so she set out to find her own! And find she does. She now uses mixed method research, using large administrative databases, community based participatory research, concept mapping and clinical trial methodologies to design, implement and evaluate interventions to prevent youth violence.  See Dr. Snider’s systematic review “Youth violence secondary prevention initiatives in emergency departments” to learn more about an important topic.

Can you think of a case that you have been involved in that has left you with unanswered questions that keep you up at night? It might be a great jumping off point for a research project!

But some have a different path to research. Andrew McRae said he was first became involved:

“The same way as a lot of people–I was a medical student looking to score a residency in Emergency Medicine. I was fortunate enough to have a supportive research supervisor who trusted me with an ambitious project that led to some important publications. It was hard work, but the payoff was enormous.”

8. Which research hero sent us a 31 page CV? 

Dr. Christian Vaillancourt

Like all of the Canadian EM research heroes, Dr. Christian Vaillancourt’s CV read less like a list of accomplishments and more like an epic saga of a man who has dedicated his career to bettering a profession and through those efforts affecting the care of a near infinite number of patients. Reading through this humbling document was a reminder to me, a junior researcher, that systematically keeping track of the projects one is involved in real time is easier than trying to create a list in retrospect. Find a system that works for you and keep it up to date.

9. Which researcher thinks the most important part of research is relationship building? 

Dr. Laurie Morrison

Dr. Laurie Morrison completed her Master’s thesis on the termination of resuscitation, a project during which she collaborated very closely with paramedics. During this research experience, and throughout her ten years as a clinician-scientist she has found that building strong relationships is what facilitates building and answering questions. Though she values strong relationships, she also stresses that you must “find yourself before working with others” (i.e. know what you have to offer, what your weaknesses are etc.) to optimize research team performance.

10. Which researcher was once fascinated by amylase? 

Dr. Eddy Lang

Eddy Lang reflected that cases related to the clinical significance of indeterminate amylase values inspired his work “The prognostic significance of moderate hyperamylasemia in the evaluation of emergency department patients” that was published during his first year on staff. Dr. Lang believes that the most important part of the research process is “curiosity and the drive to contribute beyond clinical medicine and commitment to developing the non-clinical side of your brain”. He knows a great deal about all three of those things!

11. Which hero performed research in Sudbury, Ontario? 

You bet, it was Dr. Brian Rowe who is both a “gentleman and a scholar” which is exactly how he

Dr. Brian Rowe

describes Sir Iain Chalmers, the scientist with whom he would most like to work. In the cold tundra of northern Ontario, Dr. Rowe  examined the effectiveness of inhaled budesonide + prednisone vs placebo + prednisone. He describes the project as “really hard work but like a marathon, fun when it was over.”….really, a marathon is fun? Really? Anyhow, this project proved to Dr. Rowe that with a good question, dedicated colleagues and committed funders research can be done in non-academic centres.

You should be convinced too! No matter what location you end up in, there are questions to be asked and answers to be found. Take note, high-quality research can be performed anywhere, anytime!

12. Which hero used the term sweat equity to describe a researcher’s contribution to a project? 

Dr. Andrew McRae

Dr. Andrew McRae understands that you don’t have the financial equity to fund research but what you lack in $ you can contribute in sweat. He believes, as I am sure many of the other research heroes would, that:

“The best projects are ones that you are passionate about and willing to put a substantial amount of time and sweat equity into–the results will be more meaningful and you’ll learn a lot more.”

He suggests that you “shouldn’t look for small projects that you can have a tiny peripheral role in (there’s no such thing if you don’t want to waste your and your supervisor’s time).”Dr. McRae encourages young researchers to find or create a project that they can make their own and learn from as it progresses.

13. What was the most common tip from the Canadian EM Research heroes for juniors looking to get involved in research? 

It was a close tie between “finding something you are passionate about” and “finding a good mentor”. I guess that the two are probably related. A practical tip from Dr. Lang, is to read the David Sackett article “On the determinants of academic success as a clinician scientist“. This seems a very wise suggestion, and a great place to start!

Stay tuned for more great tips from Dr. Rob Green later this week!

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post BoringEM Research Week | Guess Who? Canadian EM Research Edition appeared first on BoringEM and was written by Eve Purdy.

The Case of the Missing Awake Intubation Kit: Episode 1

Part I: The anaphylactic patient

This post is the first of a planned three-part series. In this introduction, I realize that my trauma bay does not have an awake intubation kit. This article, however, is not about awake intubation itself, as there are already many articles out there. Instead, it is about the logistical challenges of not having a ready kit, and a call for input from the social media community. – Daniel

 

***

Having napped poorly before a night shift, I am caffeinating myself when the trauma nurse tells me about a patient who is having an allergic reaction and needs to be seen right away.

 

Clearing the cobwebs from my eyes, I go to the trauma bay, where the paramedics are rolling in an elderly woman named Agnes. Agnes is sitting upright on the stretcher, her chin cocked into a sniffing position, and mouth-breathing at 50 breaths per minute.

 

Her tongue is red, enormous, and wet with saliva. She can hardly talk. From her husband and her medication list, we learn that Agnes takes a few cardiac medications, but there have been no recent additions or changes. One of these medications is an angiotensin-converting enzyme (ACE) inhibitor, although she has been on the medication for years without incident.

 

We throw the kitchen sink of anaphylactic treatments at Agnes: epinephrine, Benadryl, famotidine—we even order C1 esterase inhibitor. Nothing seems to quell the inflammation and an airway intervention looms.

 

Given the pathologic, inflamed airway, a standard rapid-sequence intubation is risky, as neuromuscular blockade could precipitate a disastrous closed airway after protective reflexes are abolished [1]. Instead, we discuss performing an “awake look” to visualize the anatomy first with protective reflexes present, before attempting to pass the endotracheal tube through the vocal cords.

 

We predict a difficult airway; in addition to the swollen anatomy, Agnes also has a short, arthritic neck. We call our anesthesia colleagues to help. In the meantime, we landmark and prep the neck and open a cricothyrotomy kit by the bedside.

 

As we wait for our anesthesia colleagues, we begin to apply topical anesthetic to the upper airway by nebulizing lidocaine. Someone tells us our hospital has stopped carrying 4% lidocaine, so we nebulize a 2% solution. We also administer glycopyrrolate to decrease secretions.

 

When the anesthesia attending arrives, he agrees with our plan to do an awake intubation, and wants to topicalize down to the vocal cords. He asks for a specific mucosal atomization device (MADgic), but we do not carry it in the Emergency Department. We scrounge up a few different devices in the department, but the anesthesiologist calls the operating room for his preferred device. It takes what seems like forever for the atomizer to arrive. In the meantime, our patient is stable but looking increasingly uncomfortable.

 

 

Atomizer Picture

Figure 1. This laryngo-tracheal mucosal atomization device attaches to a standard syringe [1].

 

Fortunately, my case has an uneventful ending. The atomizer arrived, we finished topicalizing the airway, and we are able to get a Grade 1 view with our video laryngoscope. (Finding out the patient wore dentures was a bonus.) We passed through the cords easily, and then sedated and paralyzed the patient. We congratulated one another on a job well done and a disaster averted.

 

Afterward, one of the emergency physicians observed that we re-invent the wheel every time we do an awake intubation, assembling an ad hoc collection of drugs and devices. I wondered if the long delays associated with not having a pre-assembled kit could lead to patient harm in the future.

 

My question to the social media community is this:

 

Over the next couple of months, my colleague, Jared Baylis, and I will be assembling an awake intubation kit for our Emergency Department.

We would like to invite you all to help us.  Please join and share in the spirit of #FOAMed in the comments below.

 

Questions to the Audience:

1) Do you have a kit in your shop? If so, what are your practical, trusty go-to ingredients?

 

2) What does your ideal awake intubation kit look like? 

 

In particular, we are interested in hearing practical input into the various approaches to topical anesthetic and whether choice is situation-dependent.

 

In part II of this series, Jared and I will be using your ideas and meeting with some local airway experts to gather their insight into their practice preferences. In part III, we will be assembling the kit and posting it online for viewing, critique and commentary.

 

 

References:

 

  1. Schwartz, R.B., Shepherd, G (2014). Pharmacologic adjuncts to intubation. In: Roberts, J.R., Custalow, C.B., Thomsen, T.W., & Hedges, J.R. Roberts and Hedges’ clinical procedures in emergency medicine. 6th ed. Elsevier Saunders, Philadelphia, PA. 118-119.

 

Reviewing with the Staff
This post has been reviewed by Dr. Alim Pardhan (@alimpardhan), assistant professor at McMaster University and clinical site lead at Hamilton General Hospital.

This is an excellent example of how frustration, or a cardinal event, can lead to innovation and process changes in the clinical environment. Making changes in the clinical environment can sometimes be frustrating, but can also be rewarding when everything finally comes together. The process that you follow to make changes is variable, but having a process can be helpful in ensuring that everything gets done.

There are a number of tools that exist to help with managing these types of changes, most of which are available online. Here, however, are some practical tips:

  • Ensure that you have a clear target. What are you trying to achieve and why is it important? Identify what will success look like – not only that you “have a kit” but also what are the outcomes you hope will be managed?
  • Identify all your stakeholders. For this type of kit, this includes knowing who will be using it (e.g. ED, Anesthesia, Trauma + associated learners), who will be supporting it (e.g., RN, RT), who will be stocking it, and who will be paying for it. What are the needs of these stakeholders, and will they need training? When should they be consulted?
  • Don’t reinvent the wheel. Solicit input from others – both locally and elsewhere – for input. Someone else has likely already done this, and knowing how they solved the problem can help you avoid unnecessary work.
  • Make sure you have a process to manage all the input you get. Who will decide what goes into the kit, and how will they decide? Ideally do this before you start collecting and analysing input. One way to do this is to divide the input you receive into categories like ‘must have,’ ‘nice to have,’ and ‘don’t need’.
  • Make sure you have a process to debrief after your solution is used so that you can troubleshoot any issues that come up.
  • Have a sustainability plan. How will you make sure it gets restocked after it gets used?

Happy Building!

Author information

Daniel Ting
Daniel Ting

The post The Case of the Missing Awake Intubation Kit: Episode 1 appeared first on BoringEM and was written by Daniel Ting.

Highlighting and Translating Canadian EM Education

Three key papers were developed at the 2013 Canadian Association of Emergency Physician‘s (CAEP) Educational Scholarship Academic Symposium and published in the May 2014 edition of CJEM that explain the value of educational scholarship in emergency medicine. They outlined the importance of innovating and improving teaching and learning in our specialty [1], endorsed the support and develop scholars in EM [2], and described how we can move forward using a pragmatic “how-to” guide [3]. Since then, the Canadian EM community has worked to celebrate and recognize the work of the medical educators within our specialty. In particular, the CAEP Academic Section has been highlighting innovations in Canadian EM education through two unique projects.

The CAEP Academic Section Projects

CAEP’s academic section projects were originally devised by Dr. Jonathan Sherbino (co-chair of the Academic Section of CAEP; Associate Professor at McMaster University), and Julien Poitras (Associate professor at Laval, who also is the Dean for Faculty directions and strategic projects there). Over the past year I have worked with these two gentlemen and Jennifer Artz of the CAEP staff to co-lead two initiatives from the Academic Section of CAEP. aimed at enhancing knowledge translation in Canada:

1. Featured Educational Innovations (FEI) – A rotating series that features educational innovations from each Canadian emergency medicine program.  We are very happy to have Ken Milne (of Skeptics Guide to Emergency Medicine fame) helping to interview the innovators and create a monthly podcast (CAEP cast) that allows educators to explain their initiatives.

2. Great Evidence in Medical education Summary (GEMeS) – This is a knowledge translation project that that looks to translate medical education papers into the emergency medicine context.  This series hopes to translate some of the great knowledge out there into usable tidbits for EM educators everywhere.

More about Featured Educational Innovations

The Featured Educational Innovations (FEI) series provides educators from across Canada with an international platform to share their innovations. Their projects (along with their successes, failures, and improvements) are described in detail with the creation of a scholarly document that allows medical educators looking for new ideas to replicate their work. Check them out here.

More about GEMeS

The Great Evidence in Medical education Summaries (GEMeS)  project is a bit different.  These little write ups are “gems” that highlight key papers from medical education, and help to summarize concepts and translate them for the practicing clinician who teaches in the ED.

 

Interview with the Project Leads

Recently I had the opportunity to speak with Drs. Sherbino and Poitras about the first year of the GEMeS project. Their responses to my questions are outlined below.

Question 1:  How do you think it has gone in this pilot year?

JS:  Anecdotally, it seems to have achieved some real momentum.  The social media space within EM is promoting it, people are reaching out to me personally about the intitiative etc.  So, I think the “reach” is there.  But whether GEMeS is influencing the delivery of EM education is a big leap…

JP:  Rather well if I look at it from the ‘editing’ point of view. We succeeded in delivering on time quality material.  I agree that the global impact is not yet at a full blown level, but we have not yet a full cycle completed. The fact we are rotating through the 17 schools is a great idea, and I think it will help to raise interest and awareness of the initiative.

Question 2: How do you hope the GEMeS write ups will help Canadian EM physicians?

JS:  Education is a challenging task that too many educators approach with an ad lib attitude.  The challenge of teaching can be partially mitigated by adopting evidence-informed practices that improve the efficiency of learning.  Why use trial and error if you can build on another educator’s experience?  I have two goals for GEMeS: 1. share practical evidence and 2. increase connections within the EM education community.
JP:  The GEMeS project renders easily available a core of literature to help an EM teacher (in his/her teaching capacities).  It makes great material to choose an article for a journal club on med ed too.  It can also be used for teaching EM residents of our programs who have to acquire competencies in med ed – as bedside teaching material, as a corpus of articles to know for them (as future good teachers).  Finally, I hope that it might help to inspire new ideas/questions/studies/projects for our teachers/residents.

Question 3:  What was your thoughts on the original idea?  Has it evolved in your mind into something different over the year?

JP: Pretty much on target. One of the things that was envisioned was the possibility to receive automatically the new GEMeS monthly through email (as a subscription/feed). Currently right now, the FEI has been well integrated into the CAEP monthly newsletter, but in the next while hopefully we can similarly to this with the GEMeS project.

JS:  The original idea was a second order peer review of classic EM education publications.  A “Cole’s notes” take on education scholarship.  While GEMeS still uses great headlines, the rigour of each review is much better than I imagined.

References:

1. Sherbino, J., Van Melle, E., Bandiera, G., McEwen, J., Leblanc, C., Bhanji, F., … & Snell, L. (2014). Education scholarship in emergency medicine part 1: innovating and improving teaching and learning. CJEM, 16, S1-5.

2. Bandiera, G., LeBlanc, C., Regehr, G., Snell, L., Frank, J. R., & Sherbino, J. (2014). Education scholarship in emergency medicine part 2: supporting and developing scholars. CJEM, 16, S6-S12.

3. Bhanji, F., Cheng, A., Frank, J., Snell, L., & Sherbino, J. (2014). Education scholarship in emergency medicine part 3: a ‘‘how-to’’guide. CJEM, 16, 00-00.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Highlighting and Translating Canadian EM Education appeared first on BoringEM and was written by Teresa Chan.

Life Beyond Medicine | Why music is important to me

EDITOR’S NOTE:

Medicine can be an all-consuming pursuit.

Need proof? Sit 3-4 healthcare providers together at a table, and what is the automatic reaction? They talk about work. Recognizing this, you might have noticed that we’ve started a series entitled ‘Life Beyond Medicine’ within the Mentorship section of BoringEM.

These articles have been curated or written by the BoringEM editorial team, aiming to highlight parts of our lives outside of (or at least on the fringes of) our medical personae.

The following is my offering to this series.

- Teresa

*******

Music has always been an important part of my life – not quite an Etta James ‘At Last’ sort of love, but more of a stalwart persistent ‘Gravity’ (à la Sara Bareilles).

The beginning

I distinctly remember, at the age of 4-and-a-half, being jealous that my elder cousins were able to make amazing sounds from the big box with the black and white keys. My parents picked up on this, and being the #TigerParents they were, promptly enrolled me in piano lessons.

In two years’ time, my inattention had my mother sitting on the piano bench next to me, directing my practise. The next three years brought scolding, yelling, and disagreement, and by the next year we were at a breaking point in both my relationship with my mother and my relationship with music. Daily, I threatened to quit. Daily, my mother threatened to let me quit, but never actually did.

Then I turned 10, and my parents took me to New York City. There, I saw my first broadway musical, Les Misérables, and fell in love with music all over again. The soaring melodies of Bring Him Home, the loneliness of On My Own.: these songs reached me in a way I had never experienced before. I realized, for the first time, that music wasn’t about notes and precision. It wasn’t about rote memory or my mother sharply disciplining in my lazy practice. Music was about emotions.

A new beginning

Upon return from New York, I asked my parents if I could stop piano lessons and sing instead. After a length negotiation, we agreed that I would do both. They must have known that piano would compliment my singing, rr perhaps they felt that it would be a loss to let my piano playing skills decay.

My vocal teacher was the one who highlighted the importance of a good musical foundation and explained how crucial the piano was to my musicality. My ability to read music helped me speed through early vocal training, and I quickly learned to appreciate my piano training as a crucial adjunct to vocal music.

(*And yes, I eventually learned all my favourite ballads from Les Misérables…)

Upping the Ante

It was during high school that I began studying music history, theory, and, eventually, composition. From my music history classes, I gained a greater understanding of how connected communities of practice were built. My teacher brought dry music history to life, and described for me a PG-13 version of the Romantic era. It was full of grand love triangles (Robert Schumann, his wife Clara, and his student Johannes Brahms!), torrid complicated love affairs (Frederic Chopin and French novelist George Sand!), and circles of friends who knew and support one another’s works. From music theory classes, I learned to decipher the combinatory science that comprised the music I loved. Chord progressions, melodic riffs, counterpoint, and harmony worked together to create the brilliantly logical works of Bach, the quirky playfulness of Mozart, and the long melodic lines of Puccini.

Soon after, I decided that I should play guitar. My friends at the time were learning, and I felt it might make me seem less nerdy. (Little did I know that if I wanted to be cool, I should have picked the double bass.)

But with guitar came the idea that I might actually apply the music theory and composition skills I had only used theoretically. Guitar music, I realized, was all written as chords. I might learn to play and then sing along to these chords. Within weeks of this realization, I started writing my own pieces. I began riffing on the keyboard, the guitar, almost anything that could make a sound. I wrote lyrics, and started telling my stories via song. Song writing became an important mechanism for dealing with and processing emotions. It was just as I experienced watching Les Misérables for the first time; songs could be a way to express my darkest and deepest feelings.

Why I write music to this day

I cycle through hobbies. I will be work obsessively though a new cookbook series, only to move on to knitting an inordinate number of scarves, but I always return to song writing, Only recently have I realised that song writing is the hobby I conveniently “rediscover” each time that I find myself overwhelmed by emotion.

As a clinical clerk, I found my first clinical rotation (internal medicine) overwhelming; I was not quite ready to deal with the concept of death as a weekly occurrence. The surge of emotion I felt when my patient died during my first week, only to be followed by another in my second week hit me hard. When I realized the annual medical school talent night was upon us, I found myself drawn to my keyboard, where I sat down the night before my performance. Three hours later, with tears streaming down my face, I was able to show my roommate the final draft of a song that was emotionally authentic, and yet abstracted and fictionalized enough to maintain patient confidentiality. This song (Make things right) remains one of the most important expressions of my emotions around death and dying.

To date, this song remains the only one that purely deals with a peri-clinical experience. I have, perhaps, adapted to managing my emotions around clinical cases, and find they do not heighten my emotions in a way to now precipitate songs. My song writing now gravitates, like most other songwriters, around issues of relationships, love, and the heartbreak that comes with taking chances with those things. For me, there’s nothing like having a great, epic song writing session to sublimate and create something new from the chaos that is my life.

Tear-soaked pages filled with lyrics, haunting melodies that convey my latest yearning or ache… these are my way of releasing that which I cannot being to convey in any other way.

The lives we lead are hard… they are full of everyone else’s darkest hours – even when they are our great successes. And then we have our own trials and tribulations. Having a place to digest, consider, and process these moments… that’s what music affords me.

My music remains a very personal thing… and I think that’s the most important thing.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Life Beyond Medicine | Why music is important to me appeared first on BoringEM and was written by Teresa Chan.

Life Beyond Medicine | Why music is important to me

EDITOR’S NOTE:

Medicine can be an all-consuming pursuit.

Need proof? Sit 3-4 healthcare providers together at a table, and what is the automatic reaction? They talk about work. Recognizing this, you might have noticed that we’ve started a series entitled ‘Life Beyond Medicine’ within the Mentorship section of BoringEM.

These articles have been curated or written by the BoringEM editorial team, aiming to highlight parts of our lives outside of (or at least on the fringes of) our medical personae.

The following is my offering to this series.

- Teresa

*******

Music has always been an important part of my life – not quite an Etta James ‘At Last’ sort of love, but more of a stalwart persistent ‘Gravity’ (à la Sara Bareilles).

The beginning

I distinctly remember, at the age of 4-and-a-half, being jealous that my elder cousins were able to make amazing sounds from the big box with the black and white keys. My parents picked up on this, and being the #TigerParents they were, promptly enrolled me in piano lessons.

In two years’ time, my inattention had my mother sitting on the piano bench next to me, directing my practise. The next three years brought scolding, yelling, and disagreement, and by the next year we were at a breaking point in both my relationship with my mother and my relationship with music. Daily, I threatened to quit. Daily, my mother threatened to let me quit, but never actually did.

Then I turned 10, and my parents took me to New York City. There, I saw my first broadway musical, Les Misérables, and fell in love with music all over again. The soaring melodies of Bring Him Home, the loneliness of On My Own.: these songs reached me in a way I had never experienced before. I realized, for the first time, that music wasn’t about notes and precision. It wasn’t about rote memory or my mother sharply disciplining in my lazy practice. Music was about emotions.

A new beginning

Upon return from New York, I asked my parents if I could stop piano lessons and sing instead. After a length negotiation, we agreed that I would do both. They must have known that piano would compliment my singing, rr perhaps they felt that it would be a loss to let my piano playing skills decay.

My vocal teacher was the one who highlighted the importance of a good musical foundation and explained how crucial the piano was to my musicality. My ability to read music helped me speed through early vocal training, and I quickly learned to appreciate my piano training as a crucial adjunct to vocal music.

(*And yes, I eventually learned all my favourite ballads from Les Misérables…)

Upping the Ante

It was during high school that I began studying music history, theory, and, eventually, composition. From my music history classes, I gained a greater understanding of how connected communities of practice were built. My teacher brought dry music history to life, and described for me a PG-13 version of the Romantic era. It was full of grand love triangles (Robert Schumann, his wife Clara, and his student Johannes Brahms!), torrid complicated love affairs (Frederic Chopin and French novelist George Sand!), and circles of friends who knew and support one another’s works. From music theory classes, I learned to decipher the combinatory science that comprised the music I loved. Chord progressions, melodic riffs, counterpoint, and harmony worked together to create the brilliantly logical works of Bach, the quirky playfulness of Mozart, and the long melodic lines of Puccini.

Soon after, I decided that I should play guitar. My friends at the time were learning, and I felt it might make me seem less nerdy. (Little did I know that if I wanted to be cool, I should have picked the double bass.)

But with guitar came the idea that I might actually apply the music theory and composition skills I had only used theoretically. Guitar music, I realized, was all written as chords. I might learn to play and then sing along to these chords. Within weeks of this realization, I started writing my own pieces. I began riffing on the keyboard, the guitar, almost anything that could make a sound. I wrote lyrics, and started telling my stories via song. Song writing became an important mechanism for dealing with and processing emotions. It was just as I experienced watching Les Misérables for the first time; songs could be a way to express my darkest and deepest feelings.

Why I write music to this day

I cycle through hobbies. I will be work obsessively though a new cookbook series, only to move on to knitting an inordinate number of scarves, but I always return to song writing, Only recently have I realised that song writing is the hobby I conveniently “rediscover” each time that I find myself overwhelmed by emotion.

As a clinical clerk, I found my first clinical rotation (internal medicine) overwhelming; I was not quite ready to deal with the concept of death as a weekly occurrence. The surge of emotion I felt when my patient died during my first week, only to be followed by another in my second week hit me hard. When I realized the annual medical school talent night was upon us, I found myself drawn to my keyboard, where I sat down the night before my performance. Three hours later, with tears streaming down my face, I was able to show my roommate the final draft of a song that was emotionally authentic, and yet abstracted and fictionalized enough to maintain patient confidentiality. This song (Make things right) remains one of the most important expressions of my emotions around death and dying.

To date, this song remains the only one that purely deals with a peri-clinical experience. I have, perhaps, adapted to managing my emotions around clinical cases, and find they do not heighten my emotions in a way to now precipitate songs. My song writing now gravitates, like most other songwriters, around issues of relationships, love, and the heartbreak that comes with taking chances with those things. For me, there’s nothing like having a great, epic song writing session to sublimate and create something new from the chaos that is my life.

Tear-soaked pages filled with lyrics, haunting melodies that convey my latest yearning or ache… these are my way of releasing that which I cannot being to convey in any other way.

The lives we lead are hard… they are full of everyone else’s darkest hours – even when they are our great successes. And then we have our own trials and tribulations. Having a place to digest, consider, and process these moments… that’s what music affords me.

My music remains a very personal thing… and I think that’s the most important thing.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Life Beyond Medicine | Why music is important to me appeared first on BoringEM and was written by Teresa Chan.

Nice threads: a guide to suture choice in the ED

Introduction

In your first Emergency Department (ED) rotation, you are keen to practice your suturing technique. During a slow shift, you decide to take a look at the suture cart in minor treatment, and realize you can only recognize two of the types available. What is the difference between these sutures and how can you apply them to different presentations? What is the right suture choice? Suture choice

Often, suture choice is not explicitly taught in medical school and is learned informally. This post aims to explain differences between basic suture types as well as how key patient and wound factors may influence choice. We use a few cases to illustrate, and have searched the literature for the best-available evidence.

The Clinical Question

In patients presenting with lacerations to the ED, how should physical characteristics of the suture type influence choice for primary closure?

Objectives

  • To review common suture types used in the ED.
  • To describe applications of suture types and techniques based on anatomical location and depth.

Overview

Conceptually, suture types can be divided into four categories: absorbable braided, absorbable monofilament, nonabsorbable braided and nonabsorbable monofilament.

Suture types available in the Kelowna General Hospital ED, divided by type.  N.B., “Ethilon” is a nylon nonabsorbable suture. Prolene is a polypropylene nonabsorbable suture that is used in other EDs for similar applications as Ethilon/nylon.

Suture types available in the Kelowna General Hospital ED, divided by type.
N.B., “Ethilon” is a nylon nonabsorbable suture. Prolene is a polypropylene nonabsorbable suture that is used in other EDs for similar applications as Ethilon/nylon.

 

 

 

 

 

 

 

 

 

Type of SutureTime to 50% breaking strength retentionTime to complete absorption
Vicryl Rapide5 days42 days
Fast Absorbing Gut7 days21-42 days
Monocryl1 week91-119 days
Vicryl3 weeks56-70 days
Chromic Gut3-4 weeks90 days

Absorbable sutures do not need to be removed, but are theoretically more inflammatory and may be more likely to be infected. Braided sutures are stronger and their knots are less likely to slip—thus requiring fewer throws and can be cut with short ends—but are more liable to become infected. For the absorbable types, long-lasting sutures provide durable tensile strength but again, have higher infection rates.

We can use this knowledge in the following cases!

The Cases

A series of cases designed to dive into choosing the right suture material!

Case 1- the uncomplicated adult lacerationCase 1 sutures

An otherwise healthy 34-year-old female presents to the ED after cutting the anterior surface of her left leg in a kitchen accident. Following examination you are confident there is no tendon, nerve, or vascular involvement in this clean, 6 cm laceration. What is the best suture type to use?

Answer

There are many factors that go into selecting a suture type. These include tensile strength required for wound closure, site anatomic location of the wound closure, and ability to return for follow up. It is generally accepted that if one uses sutures to repair an uncomplicated laceration, the best choice is a monofilament non-absorbable suture. Monofilament synthetic sutures have the lowest rate of infection [2]. Size 6-0 is appropriate for the face. 3-0, 4-0 or 5-0 may be appropriate for other areas including torso, arms, legs, hands and feet[1] [4]. In general, the smallest diameter that can effectively support the tension on the wound is preferable.

Bottom line: General consensus has been that, when using sutures to repair an uncomplicated laceration in an adult patient, a monofilament non-absorbable suture is preferable (e.g., Ethilon). Most current wound care practices are empirical or based on animal models. To date there are few well-designed clinical trials [5]. However, recent literature has shown similar cosmetic results when comparing absorbable versus non-absorbable suture repair in pediatric patients [6]. This may be generalizable to adult populations, although further research is needed (see case 3).

Case 2- the macerated laceration

A 41 year-old male presents to the ED after he caught his hand on an exposed nail causing a 3 cm laceration with macerated edges that are not well approximated. How important is debridement?

Answer

In a 2001 cross-sectional study by Hollander et al. involving over 5,000 patients with traumatic lacerations, there was a 3.5% wound infection rate [5]. Macerated wound edges were associated with increased rate of infection [7]. The authors postulated that debriding contaminated, macerated tissue to provide smoother wound edges may reduce risk of infection. A literature search revealed little evidence outside of surgical and military literature regarding traumatic lacerations. It is generally accepted, however, that removing devitalized tissue aids in wound healing [8]. If the macerated edges are viable, it is important to carefully bring the edges together with sutures to allow superior cosmesis [2].

Bottom Line: Lacerations with macerated edges are associated with higher risk of infection. Debridement of devitalized tissue to provide smooth wound edges is preferable for wound healing.

Case 3- the uncomplicated pediatric laceration

A 6-year-old girl presents with a 3 cm clean-appearing laceration over the left cheek after falling against a metal table. Is the use of an absorbable suture acceptable?

Answer

In cosmetically sensitive areas, sutures are often preferable to skin glue, because they provide more precise apposition of tissue, especially in the pediatric population, whose high skin elasticity predisposes to scar widening over time [9]. The traditional teaching has held that the use of non-absorbable sutures provide a better cosmetic result because they are less inflammatory and reduce the risk of “railroad track” scarring in the skin. However, in the pediatric population, suture placement and removal can be traumatic. Therefore, the use of absorbable sutures may be preferable since they do not need to be removed. A trio of studies performed in Pediatric EDs showed absorbable catgut sutures provided similar cosmesis to nonabsorbable nylon after several months, with no differences in parental satisfaction or wound complications [10-12].

In the adult population, absorbable sutures have long been accepted in the surgical fields, where numerous studies have shown no cosmetic difference between absorbable and nonabsorbable, although whether these results apply to the ED is debatable. Recently, a small ED study examined cosmetic outcomes for extremity repair in adults and found similar cosmesis between Vicryl Rapide and Prolene, although the Vicryl Rapide group had an 11% risk of infection [6]. Another prospective study found no cosmetic difference for facial wounds repaired by fast-absorbing gut, nylon or tissue adhesive, although the study lost almost half its cohort in follow-up [13]. Further study is likely required.

Bottom line: When sutures are indicated for a clean wound on a child’s face, fast-absorbing catgut sutures allow similar cosmesis to non-absorbable sutures. Thus, they are an acceptable alternative, especially if the provider perceives the child may have significant anxiety with suture removal.

Case 4- the deep laceration

http://tinyurl.com/jwxulhf A 52-year-old farmer presents to the Emergency Department after a mishap with a saw. He has a clean-appearing 6 cm laceration. After local anesthesia and irrigation, you notice that the laceration extends deep to adipose tissue. Is there a role for deep sutures?

Answer

When wounds extend to the deep dermis, they are often subject to higher tension. Closing a deep wound under tension increases the risk of scarring as well as complications, such as dehiscence [2,14]

A technique of using absorbable sutures in the dermis and subcutaneous layers can allow the relief of tension and approximate wound edges. Deep sutures can be done in an interrupted fashion. On the initial throw, the needle should be inserted in the deep dermal layer and exit in the superficial dermal layer (deep-to-superficial). On the second throw in the opposite margin of the wound, the needle first enters the dermis and exits the deep dermal layer (superficial-to-deep). This allows the knot to be buried deep in the wound, which prevents the knot from forming an uncomfortable bump and from interfering with dermal healing [2,14].

Keep in mind the following:

  • The number of deep sutures should be kept to a minimum since each suture is a foreign body and a possible nidus of infection [2]. A wound under suspicion of contamination should be closed without deep stitches.
  • Avoid suturing adipose tissue as it does not provide good purchase (grip) and only increases the risk of infection [2,14]
  • In facial lacerations, an ED study found that using deep sutures in simple wounds smaller than 3 cm did not result in a cosmetically superior outcome than simply closing the skin with nonabsorbable suture [15].

Once deep sutures have been placed, the epidermis can be closed in the usual fashion.

Bottom line: When sutures are indicated in a deep laceration, the judicious use of interrupted, absorbable sutures (e.g., Vicryl) can relieve skin tension, ease closure and improve ultimate cosmetic outcome. Vicryl is often a good choice here because it provides long-term tensile strength and has a mid-range absorption time, which reduces foreign body infection risk (Table 1).

 

Reviewing with Staff (Brian Lin)

Reviewer: Brian Lin, MD, FACEP. Dr. Lin is an attending physician at Kaiser Permanente, San Francisco, and a Clinical Assistant Professor at UCSF. He is the author of the awesome emergency medicine wound care website, www.lacerationrepair.com.

Bottom Line

The authors give an excellent summary of the ‘boring’ but essential topic of suture selection and basic closure techniques for many common wounds seen during an ED shift. While peering in to a suture cart and envisioning how to perform a closure can be intimidating for the new learner, the process is much simpler if some basic tenets are kept in mind:

  • The best suture for a given laceration is the smallest diameter suture, which will adequately counteract static and dynamic tension forces on the skin.
  • The stronger an absorbable suture is, the greater its absorption time, and the greater its risk of causing a foreign body reaction within a wound. This principle is especially important when considering the use of buried sutures (such as interrupted deep dermal sutures) or planned non-removal of epidermal sutures (as discussed in Case 3).

The authors briefly discuss the techniques of simple interrupted suturing, both for superficial skin closure and for deep dermal placement. These are essential techniques for the new learner to master, as almost any traumatic laceration can be repaired with knowledge of these techniques alone. As skills develop, additional techniques for more efficient and elegant closure can be added to the practitioner’s armamentarium.

References

  1. Retrieved from http://www.ethicon.com/healthcare-professionals November 14, 2014.
  2. Simon, B.C., Hern, H.G. (2014). Wound management principles. In: Marx, J.A., Hockberger R.S., Walls R.M., et al. Rosen’s Emergency Medicine Concepts and Clinical Practice. 8th Ed, Vol 1. Elsevier Saunders, Philadelphia. 2014, 756-763.
  3. Retrieved from http://www.pharmacopeia.cn/v29240/usp29nf24s0_m80200.html November 19, 2014.
  4. Thomsen, T. W., Barclay, D. A., & Setnik, G. S. (2006). Basic Laceration Repair. New England Journal of Medicine, 355(17), e18.
  5. Hollander J., & Singer, A. (1999). Laceration Management. Annals of Emergency Medicine, 34(3), 356-367.
  6. Tejani, C., Sivitz, A.B., Rosen, M.D, Nakanishi, A.K., Flood, R.G., Clott, M.A., …& Luck, R.P. (2014). A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures. Academic Emergency Medicine, 21(6), 637-643.
  7. Retrieved, from http://www.who.int/hac/techguidance/tools/guidelines_prevention_and_management_wound_infection.pdf October 16, 2014.
  8. Retrieved from http://www.med.uottawa.ca/procedures/wc/e_treatment.htm#c3 October 16, 2014.
  9. Parell, G.J., Becker, G.D. (2003). Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. Archives of Facial Plastic Surgery, 5(6), 488-490.
  10. Karounis H., Gouin S., Eisman H., Chalut, D., Pelletier, H., & Williams, B. (2004). A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Academic Emergency Medicine, 11(7), 730-735.
  11. Luck, R.P., Tredway, T., Gerard, J., Eyal, D., Krug, L., & Flood, R. (2013). Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatric Emergency Care, 29(6), 691-695.
  12. Luck, R.P., Flood, R., Eyal, D., Saludades, J., Hayes, C., & Gaughan, J. (2008). Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatric Emergency Care, 24(3), 137-142.
  13. Holger, J.S., Wandersee, S.C., & Hale, D.B. (2004). Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. American Journal of Emergency Medicine, 22(4), 254-257.
  14. Singer A.J., & Hollander, J.E. Methods for Wound Closure. In: Tintinalli, J., Stapczynski, J., Ma, O., et al. Tintinalli’s Emergency Medicine: A comprehensive study guide. 7th Ed. McGraw-Hill Medical, New York. 2011, 306-310.
  15. Singer A.J., Gulla J., Hein, M., Marchini, S., Chale, S., & Arora, B.P. (2005). Single-layer versus double-layer closure of facial lacerations: a randomized controlled trial. Plastic and Reconstructive Surgery, 116(2), 363-368.
  16. “Michele’s Wound”. By Aaron. Retrieved from http://tinyurl.com/nqhqalb January 15, 2015.
  17. “A Wound”. By Max Sparber. Retrieved from http://tinyurl.com/nl26mfd January 15, 2015.
  18. “Such Fragile Beings”. By mi.a. Retrieved from http://tinyurl.com/jwxulhf January 15, 2015.

 

About the Authors:

This article was co-written by Dr. Daniel Ting (@tingdan) and Dr. Jared Baylis (@baylis_jared).  The are both residents at the University of British Columbia.

Daniel is UBC Royal College Emergency Medicine resident at Kelowna General Hospital. He tweets about medicine and FOAM @tingdan.

Jared is also a UBC Royal College Emergency Medicine resident based in Kelowna, BC. He is a new contributor to #FOAMed and also a father of two busy boys.

Author information

Daniel Ting
Daniel Ting

The post Nice threads: a guide to suture choice in the ED appeared first on BoringEM and was written by Daniel Ting.