046 | Sensory Innervation of the Foot

Welcome back to the Anatomy for EM podcast. Today we cover the innervation of the foot through the lens of the ankle block.

So, yes this is another very much exam focused one. Ankle blocks are certainly handy but I always find that the foreign body is right on the overlapping border of all the territories and you end up having to block everything.

These days it might just be easier to an ultrasound guided sciatic and get everything you need but I digress…

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RCEM Learning FOAMed Workshop: Audio Editing

For more details on the workshop go to RCEM Learning

The RCEM Leaning Podcast Process

For more detail on how we produce the RCEM Learning Monthly Podcast see this video. The workflow is designed to be as efficient as possible and enable clinicians with less technical ability to act as editors for the monthly podcast. Single track editing (see below) and Auphonic have made the process so much quicker. That and ensuring we get the best possible audio the first time round.  I find Trello an invaluable way to keep organised for this. We use Slack for the rest of our communication and witty banter…

Right off the bat you need to know there are multiple ways to do this. I’m gonna show you my approach with GarageBand and Audacity (even though personally I use adobe audition). There is no single right program. We can chat about pros and cons but both of these are free and that’s not a bad place to start

This assumes you know how to record some audio into a device like an H1 or directly into one of these pieces of software.


For the record I have a Rode NT1A condenser mic on a home made boom stand in my office. This goes into a cheapo Behringer desk that goes into my computer. i’d love a 2i2 but can’t justify the spend. All this gear I had from a previous life where I did some music stuff.

For recording live interviews I mostly use a Zoom H1 with two dyanmic mics plugged into it. These are usually Q2U (the European equivalent of the ATR 2100...) but any dynamic mic would work fine and some of the other guys use SAQ7s which work great. You need one of these splitters for a tenner. You have to know how to split a stereo track to mono to use that system. If you don’t want the hassle you could use a zoom H4n but it’s a big step up in price.

For more than 2 people I use a zoom H6 (which as of today was only £220 which is a great offer – it’s usually £350).

For remote recordings I use Zencastr.

Below are some very basic instructions for how to edit audio using some free programs


Adjusting levels: you can use something like auphonic to do this for you (which is a great idea I think) or you can adjust it manually. First off we’ll look at doing it for the whole track.

This bit of audio looks a bit quiet so we can adjust the volume using the slider on the left









You can also increase a certain sections volume using the “envelope tool”

When clicked you can make the audio quieter

Or louder

You can also set it to fade in or out

What if we want to delete a bit – say when someone coughed or when they went on a tangent and you want to remove it. First highlight the offending section using the “selection” tool

Now just press backspace and it disappears and the audio slides together to form a smooth join.

This is often referred to as a “ripple delete” function and it’s really nice as Garage Band doesn’t do this and when you delete a section you have to manually move the right hand section to meet the left section and close the gap you’ve just made.

Now we want to add this little intro clip before the main interview. At the minute they’ll play on top of one another.

By using the “time shift” tool now we can move the main interview so it starts playing at the end of the intro clip

If you wanted to add music just add it as another track and adjust the volume on that track so the music is nicely in the background of your introduction

Now you’re ready to export your file.


This is where most mac people start as it looks pretty and is reasonably intuitive. However it’s not especially podcast friendly. That being said Anton Helman still uses it for editing and he’s a real tech head and podcast legend.

First off always make sure you’ve turned off the EQ and effects. Sometimes GarageBand has these on automatically when it’s trying to be “helpful” and you don’t want them at this stage.

Adjusting volume is similar to audacity, there’s a little slider that moves left and right adjusting the level for that track.

You can do fade in and fade outs using the “automation” feature.

The crazy snake thing i’ve drawn as a fade is purely for demonstration and would not be useful in real life…

Cutting out a section of audio is a bit trickier. There’s no highlight feature here so instead you move the playhead to the beginning of the section you want to remove.

Then you “split” the track

You then split the track again at the end of the section you want to delete

And press back space to delete that section

The problem as you can see now is that there’s a big gap of silence between the two parts. You have to slide the right hand section to meet the left hand section to make the gap disappear

Moving and aligning tracks with garageband is really easy. You just click and hold and move them.

Once you’re happy with things then export your final file.

Two track v single track editing

Let’s say you’re editing an interview between two people. If you’re doing it right you’ll have got each person on their own audio track. It’ll look something like this on garage band

If I want to remove a section i have to make sure i remove the same amount of time from each track as otherwise the audio won’t be aligned and there’ll be a delay between one person’s audio and the other.

This means a lot of clicks and moving just to remove a couple of sections of audio. This is where editing can become incredibly time consuming.

When it comes to the final edit of one of these tracks I like to edit it as a single track with both people on the same track. You can use auphonic multitrack to match the volume levels presuming the two tracks are fairly clean to start with. You can see more about that on the video on RCEM Learning Production above.

If you prepare your two tracks correctly you end up with something looking like this.

On this single track are two voices talking back and forth. You can tell just by looking at the waveform that the levels are fairly equal. Now I can clip out sections i don’t want with half the number of clips. Or even better if i’m doing this on audacity I have the “ripple delete” function where i highlight what I don’t want press backspace and the section removes and the right hand side is automatically moved towards the left hand side without me having to move the clips.

Especially when you have someone more non technical doing your “clinical editing” (deciding what goes in and what doesn’t go into the final audio product) this can be a massive time saver. There are some disadvantages that if you find a noise (like a cough) in the track after it’s been merged into a single track then you can’t silence it. It also works better if you have reasonably good quality audio to start with.

Further reading:


RCEM Learning FOAMed Workshop: Departmental websites

For more details on the workshop go to RCEM Learning

This came up on the day as something people were quite interested in. Common interests were

  • Induction programs
  • Storing and collating the departmental teaching activities
  • Storing and organising guidelines
  • Promotion of your ED and improving recruitment

As we saw on the day setting up a website is fairly straightforward. We highlighted the pros and cons of a woprdpress.com versus a self hosted site and most seemed to lean towards the self hosted for all the added functionality available

A number of people raised concerns about representing a hospital department outside the official sanction  of the trust. This is very legitimate and I would encourage you to speak with your communications team and even IT folk. The best example i’ve seen of a department website is the one from Edinburgh Royal Infirmary. They promote the department and haven’t shied away from engaging patients and helping them with their journey through the ED. A site like this will only improve the reputation of the trust.

Assuming you’ve got permission (or asked for forgiveness…) let’s look at a few things you could do

Induction Programs

This is relatively low hanging fruit in my opinion. We have so many juniors rotating so frequently that need to have some kind of ED specific induction so that they’re up to speed with for example the ED approach to chest pain (as opposed to the medical team’s approach to chest pain.) Traditionally this involves giving the same lecture every 4-6 months to a new group of juniors.

There’s no reason that this can’t be done as an online educational module to be completed in the first week of their rotation.

As a little aside please be sure and arrange appropriate remuneration for this. If you’re asking them to do 6 hours work then this needs facilitated in the rota NOT as something to do in their free time.

I set up a very basic induction series in a couple of hospitals I’ve worked and I’ll run you through the technical side of these. Be aware that the success of this still depends on someone ensuring that the docs complete the module which hasn’t always happened in the institutions I’ve been in.

Of note St Emlyns have been doing this for years and at a much higher level. All I’m doing here is documenting my very simple and fumbling efforts.

In this department site we had an SHO induction.

We created a number of modules for our doctors to complete.

In this example the educational material was a 15 minute video produced by SEMEP, these are freely available online and are set at about the right level for a new junior doctor coming to your ED. It would probably be better to record your own local material but there are lots of great resources already out there.

After watching the video they are expected to answer a few short questions on an embedded google form. This is one of the key steps – not because the questions are a particularly good way to assess learning but they do ensure that the doctor has actually watched the material. For those with a requirement to have a documented induction then this process ensures a paper trail that it actually happened. I am well aware that this does not make it effective education.

You can set as many questions as they like. I used 5. As mentioned the questions are mainly there to show the trainee as watched the material.

Once submitted the google form will populate a google spreadsheet.

There are some limitations with this as a lot of trusts will block video sites and any google apps so that your trainees won’t be able to complete the form or even see the video sometimes. It would also be nice to be able to automatically generate a certificate of completion once all the induction modules are complete.

This can be reviewed by the educational supervisor to ensure trainees have completed te module. Using google scripts you can set up more advanced functions like automatically generated emails when a trainee completes a module. This may have improved in the past few years since i set this up but i found it quite cumbersome at the time.

There are better ways to do this using Learning Management Systems. This is apparently a massive topic in itself and there are lots available. A local colleague put me on to Namaste and Watu quizzes

This is a lot more structured and allows you to assign and monitor an individual’s learning in much more detail.

It’s a plugin in wordpress and while a little cumbersome, it’s free and fairly easy to use.

I used the same videos from SEMEP but for the questions I used the Watu Quizzes plug in. This allows you to design all the questions within wordpress and it got round the firewall issue we had with google forms.

As you can see the end result is very similar to our initial example.

The nice thing is Namaste can be setup to email a pdf certificate of completion at the end of all the modules.

I think this is a better way to do it overall but it is a bit more cumbersome in the set up.

Again, as we discussed – this does not make your education any better in any way, it can help with dissemination and administration of your education but if your education was a bit crap to start with then it’ll still be crap with a website.

Storing and collating the departmental teaching activities

We all know that it’s very difficult to get everyone together for teaching at the same time. So the idea of collating and storing all your regular activity in one place is a great idea. There are various ways to do this.

  • Upload the power points
    • I think this is a particularly poor way to do things as @ffolliet is keen to remind us the slides are the least useful part of the presentation
  • Upload a recording/screencast of the presentation
    • This isn’t bad but requires either a pre or post recording of the presentation so the presenter has to give it twice
    • Or you record the screencast live which requires a reasonable degree of technical knowledge, equipment and coordination
  • You do a live recording of everything
    • This is great, see Maryland CC project as a great example of this
    • However it’s the most time, knowledge and equipment intensive.

There are lots of opportunities to use a flipped classroom model to provide good educational resources. But once again a website does not magically make this happen. If you have no one committed to engaging trainees and providing high quality education then a website will not fix this.

However if your department’s education is the bomb then you definitely should be sharing it and a website is a great way to do that.

Storing and organising guidelines

Hospital guidelines are often strewn throughout the hospital intranet and frequently difficult to find. It seems like a great idea to collate all these in one place.

However as soon as you download that pdf and upload it to your own ED bespoke site the document is no longer controlled and might be out of date and you would have no idea. There are lots of information governance issues here so I would strongly suggest engage someone else before taking hospital wide guidelines outside of the intranet

In one place I worked we had access to an ED specific guideline repository on the intranet where i could link to all the relevant hospital guidelines on the intranet. That way if that file was updated the link would either die or it would link to the new file.

In another hospital we had our own paper based ED handbook. This was ED specific and included advice about what to do with specific conditions out of hours. The ED itself took responsibility for the contents of that book. I simply digitised it on the ED website so that it was easier to find, update and link to external resources. It was also now searchable. It stays behind a password that changes every 6 months.

Promotion of your ED and improving recruitment

This can work quite well, but once again only if you actually have something decent to offer. If you offer great training opportunities then yes a website will help publicise that, but if you just want more middle grades for service provision then don’t expect much.

In one place I worked they created a number of fellow jobs with significant non clinical time (ultrasound and education for example). These were available on the ED website (but also on my own which gets significant traffic and is likely to be the deciding factor in this case…) and we had a number of staff who were investigating working in EM in Ireland and ended up applying for jobs.

Linda Dykes in Bangor has done a lot of similar work as have the EM3 team.

So a site can be useful to promote and recruit but it is not magical – you need actual substance behind it and it is not a panacea.