Author Archives: the short coat

06.25.12
by

So Rad: Radiation in Medical Imaging, The Basics

The Gist:  Although the evidence is somewhat murky because CT scans are relatively new and the data is extrapolated from atomic bomb survivors, there is about a 1 in 1000 chance that an individual exposed to 10 mSv (1 routine abdominal CT scan) will develop cancer attributable to that CT.  How this is derived can be found below (to hear it from the experts: NEJM review article).
Medicine is a science of uncertainty, and an art of probability. 
-William Osler

Radiation in medical imaging is a hot topic.  CT scans are often necessary in the Emergency Department to identify critical issues quickly, but there is a risk associated with the ionizing radiation from this imaging so it's somewhat important to have an ability to discuss this risk (cheat sheet from Academic Life In EM).

I hear rad this, milliSievert that...what's the deal?  Some of these terms are historic in nature; most medical literature uses the Sievert (Sv).

Most useful in medicine:
  • Sievert (Sv) - effective dose of radiation on biological tissue.  It's specifically designed to reflect the radiation risk in tissue.  This is the primary difference between a Sv and a Gy. 
    • 1 Sv= 100 rem.  We use milliSieverts in most medical imaging.
    • Neoplasms have typically been associated with radiation in excess of 50 mSv
  • Gray - amount of ionizing radiation energy absorbed by an object. Does not describe any biological effects.
    • 1 gray (Gy) = 100 rad.
    • No real direct interchangeability between Sv and Gy because the former is only applicable to biological tissue.
Less useful/Historic:
  • 1 roentgen = unit of radiation dose.
  • REM = roentgen equivalent in man. Amount absorbed by human tissue, depending on the type of tissue.
  • RAD = radiation absorbed dose. Work of energy absorbed by 1 roentgen (amount absorbed by 1 roentgen as it affects biological tissue). Used in mostly in industry. 
Just how much radiation are we talking about in medicine?  On average, a person receives an average background of 3-3.5 mSv by just inhabiting Earth.  

Most dialogue on radiation risk in medical imaging centers on CT scans because they utilize far more radiation than plain x-rays.  The actual radiation from CT scans seems pretty variable based on scanned organ and the CT scanner/operator.  The Smith-Bindman, et al study published in the Archives of Int Medicine estimated the actual radiation exposure of CT scans at study institutions using the dose-length product (DLP), which is an approximation of the total energy a patient absorbs from the scan, when adjusted for organ sensitivity to radiation.  It's also important to note that radiation dose depends on the type of CT scan and the effects depend on the sensitivity of the tissue in a given anatomic area.
  • Routine abdominal CT scan estimated exposure quoted as 8-10 mSv
    • Actual calculated radiation: Average 11-20 mSv (Range 4-45 mSv) (little variation with regard to with or without contrast).  
  • Multiphase abdomen and pelvis CT scanning: median 31 mSv (Range 6-90 mSv)
  • Chest CT for suspected pulmonary embolus: median 10 mSv (Range 2-30 mSv)
  • Routine head CT median:  2-3 mSv (Range 0.3-6 mSv)

So, how much does it take to cause harm?  
BEIR (Biological Effects of Ionizing Radiaiton) VII Report holds that a dose dependent, linear no-threshold relationship exists between ionizing radiation and human cancers.  Basically, this means that all exposure carries a certain probability of harm with no zero-risk dose and that the effects of multiple small doses are additive.  

The model is based on studies of the survivors of the 1945 atomic bombs in Japan.  Brenner has probably published the most popular articles translating this data into meaningful risks from medical imaging, including this paper.  The data stems from a cohort of over 120,000 individuals from the Radiation Effects Research Foundation.  A good overview of this database.  The data demonstrate:
  • ~30,000 survivors had low dose radiation exposure (5-100 mSv), approximately the same dose as many CT scans, making this cohort relevant
  • The risk of all solid cancers in this group is consistent with a linear increase in radiation dose.
    • Survivors in the dose category from 5-125 mSv (mean =34 mSv) show a significant  increase in mortality related to solid cancers (p = 0.025) (3).
  • Children are more radiosensitive than adults. The risk from exposure during fetal life, childhood and adolescence is estimated to be about 2-3 times as large as the risk during adulthood.
  • Cancers other than leukemia typically start to appear 10 years following exposure (5 years for leukemia) and the increased risk remains for the lifetime of the exposed individuals.
Cardis et al published a 15 country retrospective cohort study of industrial employees exposed to radiation on a regular basis (mostly nuclear power, n= 407,391) essentially confirms the findings of the atomic bomb studies, demonstrating that low-dose radiation is associated with an increased risk of neoplasms. 
    • Excess relative risk, 0.97 per Sv (95% Cl 0.14-1.97, statistically significant) for all cancers excluding leukemia. This estimate corresponds to a relative risk of 1.10 for a radiation dose of 100 mSv. The excess relative risk for solid cancers was higher than the estimate for the atomic bomb survivors (0.32 per Sv, not significant).  Weakness:  As a retrospective observational study, there are several confounders, including smoking.
    • Average exposure per year = 19.7 mSv (1-2 routine abdominal CT scans)
One of the major issues with this data is that these cancers are superimposed on a background cancer rate.  Additionally, there may be some selection bias and survivors may be more likely to have cancer listed as a diagnosis.

Putting the pieces together:  Children and young people are at greatest risk.
  • The Academic Life In EM blog has a handy PV card of the table from an Archives of Int Medicine study that gives quick numbers to help estimate a patient's risk.  (Aka:  your risk is 1 in ____ from this single scan). 
  • This is also a great, interactive risk calculator

Other good resources:
Dr. Sean Fox's slides on mededmasters.com provide a great visual supplement/review of basic radiation risks from imaging.
Interesting article:  Radiologists and Emergency Physicians Often See Radiation Risks and Benefits Differently


Next up..why this actually matters to clinicians 


References:

1. Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington de González A, Miglioretti DL.  Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.  Arch Intern Med. 2009 Dec 14;169(22):2078-86.

2.
  • Baumann B, Chen E, Mills A, Glaspey L, et al.  

    • Patient Perceptions of Computed Tomographic Imaging and Their Understanding of Radiation Risk and Exposure.  Annals of Emergency Medicine  Volume 58, Issue 1 , Pages 1-7.e2, July 2011

    3.  Brenner et al.  Cancer risks attributable to low doses of ionizing radiation: Assessing what we really know.  PNASvol. 100 no. 24 13761-13766
    06.25.12
    by

    So Rad: Radiation in Medical Imaging, The Basics

    The Gist:  Although the evidence is somewhat murky because CT scans are relatively new and the data is extrapolated from atomic bomb survivors, there is about a 1 in 1000 chance that an individual exposed to 10 mSv (1 routine abdominal CT scan) will develop cancer attributable to that CT.  How this is derived can be found below (to hear it from the experts: NEJM review article).
    Medicine is a science of uncertainty, and an art of probability. 
    -William Osler

    Radiation in medical imaging is a hot topic.  CT scans are often necessary in the Emergency Department to identify critical issues quickly, but there is a risk associated with the ionizing radiation from this imaging so it's somewhat important to have an ability to discuss this risk (cheat sheet from Academic Life In EM).

    I hear rad this, milliSievert that...what's the deal?  Some of these terms are historic in nature; most medical literature uses the Sievert (Sv).

    Most useful in medicine:
    • Sievert (Sv) - effective dose of radiation on biological tissue.  It's specifically designed to reflect the radiation risk in tissue.  This is the primary difference between a Sv and a Gy. 
      • 1 Sv= 100 rem.  We use milliSieverts in most medical imaging.
      • Neoplasms have typically been associated with radiation in excess of 50 mSv
    • Gray - amount of ionizing radiation energy absorbed by an object. Does not describe any biological effects.
      • 1 gray (Gy) = 100 rad.
      • No real direct interchangeability between Sv and Gy because the former is only applicable to biological tissue.
    Less useful/Historic:
    • 1 roentgen = unit of radiation dose.
    • REM = roentgen equivalent in man. Amount absorbed by human tissue, depending on the type of tissue.
    • RAD = radiation absorbed dose. Work of energy absorbed by 1 roentgen (amount absorbed by 1 roentgen as it affects biological tissue). Used in mostly in industry. 
    Just how much radiation are we talking about in medicine?  On average, a person receives an average background of 3-3.5 mSv by just inhabiting Earth.  

    Most dialogue on radiation risk in medical imaging centers on CT scans because they utilize far more radiation than plain x-rays.  The actual radiation from CT scans seems pretty variable based on scanned organ and the CT scanner/operator.  The Smith-Bindman, et al study published in the Archives of Int Medicine estimated the actual radiation exposure of CT scans at study institutions using the dose-length product (DLP), which is an approximation of the total energy a patient absorbs from the scan, when adjusted for organ sensitivity to radiation.  It's also important to note that radiation dose depends on the type of CT scan and the effects depend on the sensitivity of the tissue in a given anatomic area.
    • Routine abdominal CT scan estimated exposure quoted as 8-10 mSv
      • Actual calculated radiation: Average 11-20 mSv (Range 4-45 mSv) (little variation with regard to with or without contrast).  
    • Multiphase abdomen and pelvis CT scanning: median 31 mSv (Range 6-90 mSv)
    • Chest CT for suspected pulmonary embolus: median 10 mSv (Range 2-30 mSv)
    • Routine head CT median:  2-3 mSv (Range 0.3-6 mSv)

    So, how much does it take to cause harm?  
    BEIR (Biological Effects of Ionizing Radiaiton) VII Report holds that a dose dependent, linear no-threshold relationship exists between ionizing radiation and human cancers.  Basically, this means that all exposure carries a certain probability of harm with no zero-risk dose and that the effects of multiple small doses are additive.  

    The model is based on studies of the survivors of the 1945 atomic bombs in Japan.  Brenner has probably published the most popular articles translating this data into meaningful risks from medical imaging, including this paper.  The data stems from a cohort of over 120,000 individuals from the Radiation Effects Research Foundation.  A good overview of this database.  The data demonstrate:
    • ~30,000 survivors had low dose radiation exposure (5-100 mSv), approximately the same dose as many CT scans, making this cohort relevant
    • The risk of all solid cancers in this group is consistent with a linear increase in radiation dose.
      • Survivors in the dose category from 5-125 mSv (mean =34 mSv) show a significant  increase in mortality related to solid cancers (p = 0.025) (3).
    • Children are more radiosensitive than adults. The risk from exposure during fetal life, childhood and adolescence is estimated to be about 2-3 times as large as the risk during adulthood.
    • Cancers other than leukemia typically start to appear 10 years following exposure (5 years for leukemia) and the increased risk remains for the lifetime of the exposed individuals.
    Cardis et al published a 15 country retrospective cohort study of industrial employees exposed to radiation on a regular basis (mostly nuclear power, n= 407,391) essentially confirms the findings of the atomic bomb studies, demonstrating that low-dose radiation is associated with an increased risk of neoplasms. 
      • Excess relative risk, 0.97 per Sv (95% Cl 0.14-1.97, statistically significant) for all cancers excluding leukemia. This estimate corresponds to a relative risk of 1.10 for a radiation dose of 100 mSv. The excess relative risk for solid cancers was higher than the estimate for the atomic bomb survivors (0.32 per Sv, not significant).  Weakness:  As a retrospective observational study, there are several confounders, including smoking.
      • Average exposure per year = 19.7 mSv (1-2 routine abdominal CT scans)
    One of the major issues with this data is that these cancers are superimposed on a background cancer rate.  Additionally, there may be some selection bias and survivors may be more likely to have cancer listed as a diagnosis.

    Putting the pieces together:  Children and young people are at greatest risk.
    • The Academic Life In EM blog has a handy PV card of the table from an Archives of Int Medicine study that gives quick numbers to help estimate a patient's risk.  (Aka:  your risk is 1 in ____ from this single scan). 
    • This is also a great, interactive risk calculator

    Other good resources:
    Dr. Sean Fox's slides on mededmasters.com provide a great visual supplement/review of basic radiation risks from imaging.
    Interesting article:  Radiologists and Emergency Physicians Often See Radiation Risks and Benefits Differently


    Next up..why this actually matters to clinicians 


    References:

    1. Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington de González A, Miglioretti DL.  Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.  Arch Intern Med. 2009 Dec 14;169(22):2078-86.

    2.
  • Baumann B, Chen E, Mills A, Glaspey L, et al.  

    • Patient Perceptions of Computed Tomographic Imaging and Their Understanding of Radiation Risk and Exposure.  Annals of Emergency Medicine  Volume 58, Issue 1 , Pages 1-7.e2, July 2011

    3.  Brenner et al.  Cancer risks attributable to low doses of ionizing radiation: Assessing what we really know.  PNASvol. 100 no. 24 13761-13766
    06.16.12
    by

    Overdiagnosis vs. Reasoned Diagnosis: Trust Your Judgment

    The Gist:  Here's a paper that confirms that if a clinician doesn't think a patient has a pulmonary embolus (PE), then they probably don't. Basically, another study to make one feel secure in using Wells <2 or clinical gestalt +/- negative d-dimer.  Testing patients who are unlikely to have disease probably does more harm than good (overdiagnosis).  Check out the 7 Step Program for PE workup in June's Annals of EM.


    The Study:  Evaluation of Pulmonary Embolism in the Emergency Department and Consistency With a National Quality Measure:  Quantifying the Opportunity for Improvement
    • Prospective, multi-site, observational investigating the proportion of avoidable imaging in patients with a low pretest probability (PTP) for PE   
      • Reminder:  PTP is the likelihood that a patient has a disease before performing the diagnostic test for that disease.
    • Avoidable imaging = imaging in a patient with low PTP, with no D-dimer ordered or negative D-dimer.
    • Patients were enrolled if they had an order for a CTPA or V/Q scan by an EM physician during randomly selected "representative shifts."  
    • The physician rated the PTP per their gestalt, provided their most likely diagnosis, and documented 74 data points that included the Wells score before receiving the results of the imaging study.  
    The Results:
    • Primary outcome met:  Imaging deemed potentially avoidable (Wells <2)  in 32% of the patients, 95% CI, 31%-34% (n=1205).
    • Sub-analysis showed 29% of patients deemed low risk through clinical gestalt got avoidable imaging
    • 38% of low risk patients were imaged and 36% (n=811) of those patients had no d-dimer
    • PE found on imaging that was deemed "avoidable" by the above criteria:
      • No d-dimer: 1.3% (n=50) 
      • Negative d-dimer:  0.2%  (n=8) 
    Some Thoughts:
    • There's a generally accepted miss rate of 1.8% for PE (1).  The rate of image detected PE in the potentially avoidable images were values were under this range.
    • All sites were actively participating in PE research and this may have altered the initial imaging rate (the authors proposed a reduced rate of imaging in this cohort) due to increased awareness of PE related issues.
    • The paper doesn't tell us how important this diagnosis is, since it doesn't track a patient-oriented outcome.  Are these clinically significant PEs?  Would treatment do more harm or good in these patients?  This study doesn't answer these more murky, contested questions.
    • Authors argue that failure to perform d-dimer testing lead to potentially avoidable imaging.
    What's the big deal about testing all of these low PTP patients?
    • Dr. David Newman has a great editorial piece that suggests we really consider what it means when we begin to work someone up for a PE, including harms that outweigh the benefits in patients with a low PTP.  Direct and indirect harms from CTPA for PE include:  contrast induced nephropathy, cancer secondary to radiation (1 in 2000 risk of cancer), and major hemorrhage from treatment of the detected PE (6 month bleeding rate of 2.8%).
    • The data seems to suggest that pulmonary emboli exist on a spectrum as a disease process.  Thus, the mortality and morbidity of the high clot burden PEs in sick patients are a different story than one that appears in a low risk patient on a super-sensitive CT scan.  The benefits of aggressive therapy are clear in the massive PEs are fairly reasonable in the sub-massive PEs.  This article from the Archives of Int Med is a time trend analysis that seems to suggest that through CTPA we are diagnosing far more PEs but making less impressive advances in preventing mortality and anti-coagulation related complications. Increased diagnosis doesn't necessarily benefit the patient.
    So, then, what's a good approach to PE diagnostics?  This editorial in June 2012's Annals of EM proposes the following 7 steps:
    1. Accept that you cannot detect every single PE.  Crazy things happen, like a patient having a giant saddle embolus who was low risk by clinical gestalt, PERC negative, and low Wells (Case Report in June Annals of EM), but they're not very common.
    2. Recognize that aggressive testing may lead to more patient harm than good.
    3. Risk Stratify.  Identify patients with low PTP using your gestalt or PERC.
    4. Watchful waiting (or "masterful inactivity").  Advise a 24 hour re-check in the ED or with their PCP. 
    5. Document the medical decision making process.
    6. Don't worry so much about litigation. This study concludes that physicians ordering CTPA for PE  workup as a defensive medicine practice had less yield in the imaging (likely avoidable imaging).  
    7. Spread the word.  Basically, keep the dialogue on testing going.

    As a student, I really like this algorithm from EMCrit, since I don't quite have clinical gestalt and I'm new enough to medicine to confirm what I think with algorithms.

    On the note of overdiagnosis, LITFL has a recent blog post with some great resources at the end.

    References:
    1.  Kline Ja, Mitchell AM, Kabrhel C, Richman PB, Courtney DM.  Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.  J Thromb Haemost. 2004; 2: 1247-1255.
    2.  Havig O.  Deep vein thrombosis and pulmonary embolism. An autopsy study with multiple regression analysis of possible risk factors.  Acta Chir Scand Suppl. 1977;478:1-120
    3. Green S, Yealy D.  Right-Sizing Testing for Pulmonary Embolism:  Recognizing the Risks of Detecting any Clot.  Annals of Emergency Medicine 2012; 6: 524-526.
    06.16.12
    by

    Overdiagnosis vs. Reasoned Diagnosis: Trust Your Judgment

    The Gist:  Here's a paper that confirms that if a clinician doesn't think a patient has a pulmonary embolus (PE), then they probably don't. Basically, another study to make one feel secure in using Wells <2 or clinical gestalt +/- negative d-dimer.  Testing patients who are unlikely to have disease probably does more harm than good (overdiagnosis).  Check out the 7 Step Program for PE workup in June's Annals of EM.


    The Study:  Evaluation of Pulmonary Embolism in the Emergency Department and Consistency With a National Quality Measure:  Quantifying the Opportunity for Improvement
    • Prospective, multi-site, observational investigating the proportion of avoidable imaging in patients with a low pretest probability (PTP) for PE   
      • Reminder:  PTP is the likelihood that a patient has a disease before performing the diagnostic test for that disease.
    • Avoidable imaging = imaging in a patient with low PTP, with no D-dimer ordered or negative D-dimer.
    • Patients were enrolled if they had an order for a CTPA or V/Q scan by an EM physician during randomly selected "representative shifts."  
    • The physician rated the PTP per their gestalt, provided their most likely diagnosis, and documented 74 data points that included the Wells score before receiving the results of the imaging study.  
    The Results:
    • Primary outcome met:  Imaging deemed potentially avoidable (Wells <2)  in 32% of the patients, 95% CI, 31%-34% (n=1205).
    • Sub-analysis showed 29% of patients deemed low risk through clinical gestalt got avoidable imaging
    • 38% of low risk patients were imaged and 36% (n=811) of those patients had no d-dimer
    • PE found on imaging that was deemed "avoidable" by the above criteria:
      • No d-dimer: 1.3% (n=50) 
      • Negative d-dimer:  0.2%  (n=8) 
    Some Thoughts:
    • There's a generally accepted miss rate of 1.8% for PE (1).  The rate of image detected PE in the potentially avoidable images were values were under this range.
    • All sites were actively participating in PE research and this may have altered the initial imaging rate (the authors proposed a reduced rate of imaging in this cohort) due to increased awareness of PE related issues.
    • The paper doesn't tell us how important this diagnosis is, since it doesn't track a patient-oriented outcome.  Are these clinically significant PEs?  Would treatment do more harm or good in these patients?  This study doesn't answer these more murky, contested questions.
    • Authors argue that failure to perform d-dimer testing lead to potentially avoidable imaging.
    What's the big deal about testing all of these low PTP patients?
    • Dr. David Newman has a great editorial piece that suggests we really consider what it means when we begin to work someone up for a PE, including harms that outweigh the benefits in patients with a low PTP.  Direct and indirect harms from CTPA for PE include:  contrast induced nephropathy, cancer secondary to radiation (1 in 2000 risk of cancer), and major hemorrhage from treatment of the detected PE (6 month bleeding rate of 2.8%).
    • The data seems to suggest that pulmonary emboli exist on a spectrum as a disease process.  Thus, the mortality and morbidity of the high clot burden PEs in sick patients are a different story than one that appears in a low risk patient on a super-sensitive CT scan.  The benefits of aggressive therapy are clear in the massive PEs are fairly reasonable in the sub-massive PEs.  This article from the Archives of Int Med is a time trend analysis that seems to suggest that through CTPA we are diagnosing far more PEs but making less impressive advances in preventing mortality and anti-coagulation related complications. Increased diagnosis doesn't necessarily benefit the patient.
    So, then, what's a good approach to PE diagnostics?  This editorial in June 2012's Annals of EM proposes the following 7 steps:
    1. Accept that you cannot detect every single PE.  Crazy things happen, like a patient having a giant saddle embolus who was low risk by clinical gestalt, PERC negative, and low Wells (Case Report in June Annals of EM), but they're not very common.
    2. Recognize that aggressive testing may lead to more patient harm than good.
    3. Risk Stratify.  Identify patients with low PTP using your gestalt or PERC.
    4. Watchful waiting (or "masterful inactivity").  Advise a 24 hour re-check in the ED or with their PCP. 
    5. Document the medical decision making process.
    6. Don't worry so much about litigation. This study concludes that physicians ordering CTPA for PE  workup as a defensive medicine practice had less yield in the imaging (likely avoidable imaging).  
    7. Spread the word.  Basically, keep the dialogue on testing going.

    As a student, I really like this algorithm from EMCrit, since I don't quite have clinical gestalt and I'm new enough to medicine to confirm what I think with algorithms.

    On the note of overdiagnosis, LITFL has a recent blog post with some great resources at the end.

    References:
    1.  Kline Ja, Mitchell AM, Kabrhel C, Richman PB, Courtney DM.  Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.  J Thromb Haemost. 2004; 2: 1247-1255.
    2.  Havig O.  Deep vein thrombosis and pulmonary embolism. An autopsy study with multiple regression analysis of possible risk factors.  Acta Chir Scand Suppl. 1977;478:1-120
    3. Green S, Yealy D.  Right-Sizing Testing for Pulmonary Embolism:  Recognizing the Risks of Detecting any Clot.  Annals of Emergency Medicine 2012; 6: 524-526.
    06.16.12
    by

    Overdiagnosis vs. Reasoned Diagnosis: Trust Your Judgment

    The Gist:  Here's a paper that confirms that if a clinician doesn't think a patient has a pulmonary embolus (PE), then they probably don't. Basically, another study to make one feel secure in using Wells <2 or clinical gestalt +/- negative d-dimer.  Testing patients who are unlikely to have disease probably does more harm than good (overdiagnosis).  Check out the 7 Step Program for PE workup in June's Annals of EM.


    The Study:  Evaluation of Pulmonary Embolism in the Emergency Department and Consistency With a National Quality Measure:  Quantifying the Opportunity for Improvement
    • Prospective, multi-site, observational investigating the proportion of avoidable imaging in patients with a low pretest probability (PTP) for PE   
      • Reminder:  PTP is the likelihood that a patient has a disease before performing the diagnostic test for that disease.
    • Avoidable imaging = imaging in a patient with low PTP, with no D-dimer ordered or negative D-dimer.
    • Patients were enrolled if they had an order for a CTPA or V/Q scan by an EM physician during randomly selected "representative shifts."  
    • The physician rated the PTP per their gestalt, provided their most likely diagnosis, and documented 74 data points that included the Wells score before receiving the results of the imaging study.  
    The Results:
    • Primary outcome met:  Imaging deemed potentially avoidable (Wells <2)  in 32% of the patients, 95% CI, 31%-34% (n=1205).
    • Sub-analysis showed 29% of patients deemed low risk through clinical gestalt got avoidable imaging
    • 38% of low risk patients were imaged and 36% (n=811) of those patients had no d-dimer
    • PE found on imaging that was deemed "avoidable" by the above criteria:
      • No d-dimer: 1.3% (n=50) 
      • Negative d-dimer:  0.2%  (n=8) 
    Some Thoughts:
    • There's a generally accepted miss rate of 1.8% for PE (1).  The rate of image detected PE in the potentially avoidable images were values were under this range.
    • All sites were actively participating in PE research and this may have altered the initial imaging rate (the authors proposed a reduced rate of imaging in this cohort) due to increased awareness of PE related issues.
    • The paper doesn't tell us how important this diagnosis is, since it doesn't track a patient-oriented outcome.  Are these clinically significant PEs?  Would treatment do more harm or good in these patients?  This study doesn't answer these more murky, contested questions.
    • Authors argue that failure to perform d-dimer testing lead to potentially avoidable imaging.
    What's the big deal about testing all of these low PTP patients?
    • Dr. David Newman has a great editorial piece that suggests we really consider what it means when we begin to work someone up for a PE, including harms that outweigh the benefits in patients with a low PTP.  Direct and indirect harms from CTPA for PE include:  contrast induced nephropathy, cancer secondary to radiation (1 in 2000 risk of cancer), and major hemorrhage from treatment of the detected PE (6 month bleeding rate of 2.8%).
    • The data seems to suggest that pulmonary emboli exist on a spectrum as a disease process.  Thus, the mortality and morbidity of the high clot burden PEs in sick patients are a different story than one that appears in a low risk patient on a super-sensitive CT scan.  The benefits of aggressive therapy are clear in the massive PEs are fairly reasonable in the sub-massive PEs.  This article from the Archives of Int Med is a time trend analysis that seems to suggest that through CTPA we are diagnosing far more PEs but making less impressive advances in preventing mortality and anti-coagulation related complications. Increased diagnosis doesn't necessarily benefit the patient.
    So, then, what's a good approach to PE diagnostics?  This editorial in June 2012's Annals of EM proposes the following 7 steps:
    1. Accept that you cannot detect every single PE.  Crazy things happen, like a patient having a giant saddle embolus who was low risk by clinical gestalt, PERC negative, and low Wells (Case Report in June Annals of EM), but they're not very common.
    2. Recognize that aggressive testing may lead to more patient harm than good.
    3. Risk Stratify.  Identify patients with low PTP using your gestalt or PERC.
    4. Watchful waiting (or "masterful inactivity").  Advise a 24 hour re-check in the ED or with their PCP. 
    5. Document the medical decision making process.
    6. Don't worry so much about litigation. This study concludes that physicians ordering CTPA for PE  workup as a defensive medicine practice had less yield in the imaging (likely avoidable imaging).  
    7. Spread the word.  Basically, keep the dialogue on testing going.

    As a student, I really like this algorithm from EMCrit, since I don't quite have clinical gestalt and I'm new enough to medicine to confirm what I think with algorithms.

    On the note of overdiagnosis, LITFL has a recent blog post with some great resources at the end.

    References:
    1.  Kline Ja, Mitchell AM, Kabrhel C, Richman PB, Courtney DM.  Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.  J Thromb Haemost. 2004; 2: 1247-1255.
    2.  Havig O.  Deep vein thrombosis and pulmonary embolism. An autopsy study with multiple regression analysis of possible risk factors.  Acta Chir Scand Suppl. 1977;478:1-120
    3. Green S, Yealy D.  Right-Sizing Testing for Pulmonary Embolism:  Recognizing the Risks of Detecting any Clot.  Annals of Emergency Medicine 2012; 6: 524-526.
    06.14.12
    by

    You’ll shoot your eye out, kid! – Ocular Ultrasound

    The Gist:  Ultrasound (US)  training is a vital part of Emergency Medicine (EM) education and may play an even more important role in military, community setting.  Ocular US may prove especially useful in diagnosing and triaging patients with ocular trauma, particularly with regard to retinal detachment in the aforementioned settings.

    Recently, EM folks on Twitter debated the utility of ED US in retinal detachment. Those arguing against US dismissed the modality due to the need for an opthalmology consult regardless of the US findings.  This reminded me of a strikingly similar debate I had with a budding PGY-1 ophthalmology resident.  Their arguments have some validity; however, I think it's easy to get swept away in the comfort of 24/7 consults in the academic hospital atmosphere.  This isn't available everywhere, even in the United States, but knowing when emergent action is warranted could prevent serious morbidity.  As the "jack of all trades," EM physicians should probably be prepared for wherever their careers may land them. 

    • Case report from the military of a patient who suffered a ricochet gunshot wound to the face from an AK-47 who was initially treated for a laceration just inferior to his medial canthus.  Over the subsequent days his vision deteriorated and he was found to have a closed globe with a sluggish pupillary response to light.  Bedside US confirmed retinal detachment and the patient was transported to a combat hospital for ophthalmology care.  He did not recover his visual function in that eye.
    • The article is a pretty good read as it succinctly highlights some of the technical aspects of US for retinal detachment with photos and textual descriptions.
    This case study suggests:
    • Bedside US in the emergency setting can rapidly identify retinal detachments.
    • There is likely an incredible role in the battlefield and other remote areas.
    • Facial trauma may result in ocular trauma, which isn't immediately apparent and may have permanent deleterious consequences.  Perhaps this patient's vision could have been saved if ocular US had been performed on his first visit.
    How do I do this? 
    • As always, check out Ultrasound Podcast's amazing Ocular Ultrasound podcast featuring Dr. Chris Fox (Ultrasound Master from UC-Irvine).  Retinal detachment discussion begins at 17:45 .  They've got everything you need to be able to get started with ocular US (and handy instructions on the One Minute Ultrasound app, naturally).
    • Pearls from Dr. Chris Fox:  
      • Ensure you're dealing with a closed globe and make sure you're scanning with the eyelid closed, of course.
      • Use tons of chilled gel (reduces pressure and the high-frequency linear transducer 7.5-10 MHz
    What does US really add..besides instant gratification?
    • US can differentiate between a "mac on" and "mac off" retinal detachment, which is huge for prognosis.  Instances where the macula of the retina is not detached (mac on) is an ophthalmologic emergency.  If these aren't treated immediately, patient's can deteriorate into a "mac off" detachment, which can result in permanent vision loss (as in the patient featured in the case study).  In resource limited settings or remote areas, this may be an important way to determine patients that must immediately see an ophthalmologist from those who occupy a less precarious situation (sometimes resource allocation is an issue)
        File:Human eye cross-sectional view grayscale.png
    (Image from Wikipedia)
    • Also, ED physicians are pretty good at identifying retinal detachment, with a prospective study (n=48, with 15 EM physicians performing US) demonstrating sensitivity and specificity for RD of 100% (95%CI = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively. 
    • US in resource limited settings is feasible and growing in importance so if one is interested in disaster medicine or global medicine, this is a great skill to have.  Check out Mount Sinai's recent US education trip to Haiti, this article discusses US training in Rwanda (and there are many more like it).  
    06.14.12
    by

    You’ll shoot your eye out, kid! – Ocular Ultrasound

    The Gist:  Ultrasound (US)  training is a vital part of Emergency Medicine (EM) education and may play an even more important role in military, community setting.  Ocular US may prove especially useful in diagnosing and triaging patients with ocular trauma, particularly with regard to retinal detachment in the aforementioned settings.

    Recently, EM folks on Twitter debated the utility of ED US in retinal detachment. Those arguing against US dismissed the modality due to the need for an opthalmology consult regardless of the US findings.  This reminded me of a strikingly similar debate I had with a budding PGY-1 ophthalmology resident.  Their arguments have some validity; however, I think it's easy to get swept away in the comfort of 24/7 consults in the academic hospital atmosphere.  This isn't available everywhere, even in the United States, but knowing when emergent action is warranted could prevent serious morbidity.  As the "jack of all trades," EM physicians should probably be prepared for wherever their careers may land them. 

    • Case report from the military of a patient who suffered a ricochet gunshot wound to the face from an AK-47 who was initially treated for a laceration just inferior to his medial canthus.  Over the subsequent days his vision deteriorated and he was found to have a closed globe with a sluggish pupillary response to light.  Bedside US confirmed retinal detachment and the patient was transported to a combat hospital for ophthalmology care.  He did not recover his visual function in that eye.
    • The article is a pretty good read as it succinctly highlights some of the technical aspects of US for retinal detachment with photos and textual descriptions.
    This case study suggests:
    • Bedside US in the emergency setting can rapidly identify retinal detachments.
    • There is likely an incredible role in the battlefield and other remote areas.
    • Facial trauma may result in ocular trauma, which isn't immediately apparent and may have permanent deleterious consequences.  Perhaps this patient's vision could have been saved if ocular US had been performed on his first visit.
    How do I do this? 
    • As always, check out Ultrasound Podcast's amazing Ocular Ultrasound podcast featuring Dr. Chris Fox (Ultrasound Master from UC-Irvine).  Retinal detachment discussion begins at 17:45 .  They've got everything you need to be able to get started with ocular US (and handy instructions on the One Minute Ultrasound app, naturally).
    • Pearls from Dr. Chris Fox:  
      • Ensure you're dealing with a closed globe and make sure you're scanning with the eyelid closed, of course.
      • Use tons of chilled gel (reduces pressure and the high-frequency linear transducer 7.5-10 MHz
    What does US really add..besides instant gratification?
    • US can differentiate between a "mac on" and "mac off" retinal detachment, which is huge for prognosis.  Instances where the macula of the retina is not detached (mac on) is an ophthalmologic emergency.  If these aren't treated immediately, patient's can deteriorate into a "mac off" detachment, which can result in permanent vision loss (as in the patient featured in the case study).  In resource limited settings or remote areas, this may be an important way to determine patients that must immediately see an ophthalmologist from those who occupy a less precarious situation (sometimes resource allocation is an issue)
        File:Human eye cross-sectional view grayscale.png
    (Image from Wikipedia)
    • Also, ED physicians are pretty good at identifying retinal detachment, with a prospective study (n=48, with 15 EM physicians performing US) demonstrating sensitivity and specificity for RD of 100% (95%CI = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively. 
    • US in resource limited settings is feasible and growing in importance so if one is interested in disaster medicine or global medicine, this is a great skill to have.  Check out Mount Sinai's recent US education trip to Haiti, this article discusses US training in Rwanda (and there are many more like it).  
    06.14.12
    by

    You’ll shoot your eye out, kid! – Ocular Ultrasound

    The Gist:  Ultrasound (US)  training is a vital part of Emergency Medicine (EM) education and may play an even more important role in military, community setting.  Ocular US may prove especially useful in diagnosing and triaging patients with ocular trauma, particularly with regard to retinal detachment in the aforementioned settings.

    Recently, EM folks on Twitter debated the utility of ED US in retinal detachment. Those arguing against US dismissed the modality due to the need for an opthalmology consult regardless of the US findings.  This reminded me of a strikingly similar debate I had with a budding PGY-1 ophthalmology resident.  Their arguments have some validity; however, I think it's easy to get swept away in the comfort of 24/7 consults in the academic hospital atmosphere.  This isn't available everywhere, even in the United States, but knowing when emergent action is warranted could prevent serious morbidity.  As the "jack of all trades," EM physicians should probably be prepared for wherever their careers may land them. 

    • Case report from the military of a patient who suffered a ricochet gunshot wound to the face from an AK-47 who was initially treated for a laceration just inferior to his medial canthus.  Over the subsequent days his vision deteriorated and he was found to have a closed globe with a sluggish pupillary response to light.  Bedside US confirmed retinal detachment and the patient was transported to a combat hospital for ophthalmology care.  He did not recover his visual function in that eye.
    • The article is a pretty good read as it succinctly highlights some of the technical aspects of US for retinal detachment with photos and textual descriptions.
    This case study suggests:
    • Bedside US in the emergency setting can rapidly identify retinal detachments.
    • There is likely an incredible role in the battlefield and other remote areas.
    • Facial trauma may result in ocular trauma, which isn't immediately apparent and may have permanent deleterious consequences.  Perhaps this patient's vision could have been saved if ocular US had been performed on his first visit.
    How do I do this? 
    • As always, check out Ultrasound Podcast's amazing Ocular Ultrasound podcast featuring Dr. Chris Fox (Ultrasound Master from UC-Irvine).  Retinal detachment discussion begins at 17:45 .  They've got everything you need to be able to get started with ocular US (and handy instructions on the One Minute Ultrasound app, naturally).
    • Pearls from Dr. Chris Fox:  
      • Ensure you're dealing with a closed globe and make sure you're scanning with the eyelid closed, of course.
      • Use tons of chilled gel (reduces pressure and the high-frequency linear transducer 7.5-10 MHz
    What does US really add..besides instant gratification?
    • US can differentiate between a "mac on" and "mac off" retinal detachment, which is huge for prognosis.  Instances where the macula of the retina is not detached (mac on) is an ophthalmologic emergency.  If these aren't treated immediately, patient's can deteriorate into a "mac off" detachment, which can result in permanent vision loss (as in the patient featured in the case study).  In resource limited settings or remote areas, this may be an important way to determine patients that must immediately see an ophthalmologist from those who occupy a less precarious situation (sometimes resource allocation is an issue)
        File:Human eye cross-sectional view grayscale.png
    (Image from Wikipedia)
    • Also, ED physicians are pretty good at identifying retinal detachment, with a prospective study (n=48, with 15 EM physicians performing US) demonstrating sensitivity and specificity for RD of 100% (95%CI = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively. 
    • US in resource limited settings is feasible and growing in importance so if one is interested in disaster medicine or global medicine, this is a great skill to have.  Check out Mount Sinai's recent US education trip to Haiti, this article discusses US training in Rwanda (and there are many more like it).  
    06.12.12
    by

    P.S. – This Not-So-Sick Looking Patient May Be Septic

    The Gist:  Exercise caution in febrile asplenic patients because these folks are at an increased risk of post-splenectomy sepsis (PSS), particular encapsulated organisms and red blood cell (RBC)-based parasites.  Sepsis may present differently in these patients - maintain a high index of suspicion.  For a good case-based podcast review, check out the Splenectomy-Sepsis lecture (Episode 26) from UC-Irvine.  

    This isn't crazily, common.  Do I really need to care?
    Somewhere between a hematology lecture and my surgical rotation, I became enraptured with the spleen.  A typically unassuming organ, the spleen bridges innate immunity with adaptive immunity, houses 30% of RBCs, and cleanses the dregs of our cells.  
    • It turns out that despite the fact that patients are benefited by splenectomy, there are very important, preventable complications from our patients.  PSS is likely the most feared of these complications and is decreasing in frequency due to the utilization of prophylactic vaccines.  However, these patients become sick very quickly and may present with an atypical picture.  Furthermore, this may occur in young, otherwise healthy looking folks who can compensate (aka not your typical sepsis picture). 
    • Variable numbers of  asplenic patients aren't aware that they're at increased risk for infection - including up to 84% in a 2000 publication (2) and 50% in a 2008 paper (3).  Thus, the patient may not disclose that they've had a splenectomy.  In these patients, history can be crucial.
      • Check for splenectomy scar
      • Ask about travel, tick exposure, vaccination status, sick contacts.
    Clues that a patient may be asplenic:
    • Hemoglobinopathy (sickle cell anemia, thalassemia) 
    • Left sided abdominal surgical scar due to:
      • Hemolytic anemia (e.g. hereditary spherocytosis)
      • Trauma. Note:  S/P blunt trauma - sepsis may be less common due to the presence of accessory spleens
      • Assorted other causes: thrombocytopenia, hypersplenism, malignancy
    So, how do they present?
    • PSS is most common in the first few post-splenectomy years but can occur for decades after splenectomy.
    • Fever and rigors are the most common signs.  
    • Headache and gastrointestinal complaints (diarrhea) can be manifestations of severe pneumooccal infections and may be mistaken for gastroenteritis
    • Disseminated Intravascular Coagulation
    Suspect Organisms
    • Encapsulated bacteria (due to the production of IgM memory B cells, specially located within the spleen):   Streptococcus pneumoniae, Haemophilus influenza, and Neisseria meningitidis.  Also, Capnocytophaga canimorsus from dog bites.
    • Parasites:  
      • Malaria (Think travel to endemic areas like S.Asia, sub-Saharan Africa, etc)
      • Babesiosis - tick borne illness, especially in NY/CT and s/p RBC transfusion 
      • Ehrlichiosis - tick borne illness in the Southeast/mid-Atlantic US (1)
    • Virus:  Cytomegalovirus
    Patients with PSS deteriorate quickly, what should I do?
    • If they're septic, naturally follow the sepsis protocol.
    • Patient looks sick with a questionable/unknown vaccine history?  Give empiric antibiotics.
      • Ceftriaxone Adults: 2 g IV q12 to 24 hours, Children: 50 mg/kg IV q12 hours (1)
      • Vancomycin if S.pneumoniae penicillin resistance suspected:  Adults: 1 to 1.5 g IV q12 hours, Children: 30 mg/kg IV q12 hours (1)
    • Have a high index of suspicion for meningitis, so have a low threshold to do an LP if warranted.
    Pretty sure my patient really does just have the flu/gastroenteritis/etc, what do I do now?
    • It's recommended that asplenic patients receive prophylactic antibiotics at the onset of febrile illnesses, although this recommendation is not evidenced based.  For example, British guidelines recommend  Amoxicillin prophylaxis through adulthood.  
    • Those with adequate primary care physician coverage receive vaccines against pneumococcus, meningococcus, and haemophilus but even these are not fool proof (interestingly, over-vaccination with pneumococcal vaccine actually has a counterproductive effect on the immune system).
    • Educate. Even if they have something minor, let them know when to return to the doctor.
    References:
    1.  Pasternack, M.  Clinical features and management of sepsis in the asplenic patient.  
    2.  Di Sabatino A; Carsetti R; Corazza, G. Post-splenectomy and hyposplenic states. The Lancet378. 9785 (Jul 2-Jul 8, 2011): 86-97.
    3.  Wilkes, A, Wills, V, Smith S.  Patient knowledge of the risk of post-splenectomy sepsis.  ANZ Journal of Surgery. Volume 78, Issue 10, pages 867-870, October 2008.
    06.12.12
    by

    P.S. – This Not-So-Sick Looking Patient May Be Septic

    The Gist:  Exercise caution in febrile asplenic patients because these folks are at an increased risk of post-splenectomy sepsis (PSS), particular encapsulated organisms and red blood cell (RBC)-based parasites.  Sepsis may present differently in these patients - maintain a high index of suspicion.  For a good case-based podcast review, check out the Splenectomy-Sepsis lecture (Episode 26) from UC-Irvine.  

    This isn't crazily, common.  Do I really need to care?
    Somewhere between a hematology lecture and my surgical rotation, I became enraptured with the spleen.  A typically unassuming organ, the spleen bridges innate immunity with adaptive immunity, houses 30% of RBCs, and cleanses the dregs of our cells.  
    • It turns out that despite the fact that patients are benefited by splenectomy, there are very important, preventable complications from our patients.  PSS is likely the most feared of these complications and is decreasing in frequency due to the utilization of prophylactic vaccines.  However, these patients become sick very quickly and may present with an atypical picture.  Furthermore, this may occur in young, otherwise healthy looking folks who can compensate (aka not your typical sepsis picture). 
    • Variable numbers of  asplenic patients aren't aware that they're at increased risk for infection - including up to 84% in a 2000 publication (2) and 50% in a 2008 paper (3).  Thus, the patient may not disclose that they've had a splenectomy.  In these patients, history can be crucial.
      • Check for splenectomy scar
      • Ask about travel, tick exposure, vaccination status, sick contacts.
    Clues that a patient may be asplenic:
    • Hemoglobinopathy (sickle cell anemia, thalassemia) 
    • Left sided abdominal surgical scar due to:
      • Hemolytic anemia (e.g. hereditary spherocytosis)
      • Trauma. Note:  S/P blunt trauma - sepsis may be less common due to the presence of accessory spleens
      • Assorted other causes: thrombocytopenia, hypersplenism, malignancy
    So, how do they present?
    • PSS is most common in the first few post-splenectomy years but can occur for decades after splenectomy.
    • Fever and rigors are the most common signs.  
    • Headache and gastrointestinal complaints (diarrhea) can be manifestations of severe pneumooccal infections and may be mistaken for gastroenteritis
    • Disseminated Intravascular Coagulation
    Suspect Organisms
    • Encapsulated bacteria (due to the production of IgM memory B cells, specially located within the spleen):   Streptococcus pneumoniae, Haemophilus influenza, and Neisseria meningitidis.  Also, Capnocytophaga canimorsus from dog bites.
    • Parasites:  
      • Malaria (Think travel to endemic areas like S.Asia, sub-Saharan Africa, etc)
      • Babesiosis - tick borne illness, especially in NY/CT and s/p RBC transfusion 
      • Ehrlichiosis - tick borne illness in the Southeast/mid-Atlantic US (1)
    • Virus:  Cytomegalovirus
    Patients with PSS deteriorate quickly, what should I do?
    • If they're septic, naturally follow the sepsis protocol.
    • Patient looks sick with a questionable/unknown vaccine history?  Give empiric antibiotics.
      • Ceftriaxone Adults: 2 g IV q12 to 24 hours, Children: 50 mg/kg IV q12 hours (1)
      • Vancomycin if S.pneumoniae penicillin resistance suspected:  Adults: 1 to 1.5 g IV q12 hours, Children: 30 mg/kg IV q12 hours (1)
    • Have a high index of suspicion for meningitis, so have a low threshold to do an LP if warranted.
    Pretty sure my patient really does just have the flu/gastroenteritis/etc, what do I do now?
    • It's recommended that asplenic patients receive prophylactic antibiotics at the onset of febrile illnesses, although this recommendation is not evidenced based.  For example, British guidelines recommend  Amoxicillin prophylaxis through adulthood.  
    • Those with adequate primary care physician coverage receive vaccines against pneumococcus, meningococcus, and haemophilus but even these are not fool proof (interestingly, over-vaccination with pneumococcal vaccine actually has a counterproductive effect on the immune system).
    • Educate. Even if they have something minor, let them know when to return to the doctor.
    References:
    1.  Pasternack, M.  Clinical features and management of sepsis in the asplenic patient.  
    2.  Di Sabatino A; Carsetti R; Corazza, G. Post-splenectomy and hyposplenic states. The Lancet378. 9785 (Jul 2-Jul 8, 2011): 86-97.
    3.  Wilkes, A, Wills, V, Smith S.  Patient knowledge of the risk of post-splenectomy sepsis.  ANZ Journal of Surgery. Volume 78, Issue 10, pages 867-870, October 2008.
    06.12.12
    by

    P.S. – This Not-So-Sick Looking Patient May Be Septic

    The Gist:  Exercise caution in febrile asplenic patients because these folks are at an increased risk of post-splenectomy sepsis (PSS), particular encapsulated organisms and red blood cell (RBC)-based parasites.  Sepsis may present differently in these patients - maintain a high index of suspicion.  For a good case-based podcast review, check out the Splenectomy-Sepsis lecture (Episode 26) from UC-Irvine.  

    This isn't crazily, common.  Do I really need to care?
    Somewhere between a hematology lecture and my surgical rotation, I became enraptured with the spleen.  A typically unassuming organ, the spleen bridges innate immunity with adaptive immunity, houses 30% of RBCs, and cleanses the dregs of our cells.  
    • It turns out that despite the fact that patients are benefited by splenectomy, there are very important, preventable complications from our patients.  PSS is likely the most feared of these complications and is decreasing in frequency due to the utilization of prophylactic vaccines.  However, these patients become sick very quickly and may present with an atypical picture.  Furthermore, this may occur in young, otherwise healthy looking folks who can compensate (aka not your typical sepsis picture). 
    • Variable numbers of  asplenic patients aren't aware that they're at increased risk for infection - including up to 84% in a 2000 publication (2) and 50% in a 2008 paper (3).  Thus, the patient may not disclose that they've had a splenectomy.  In these patients, history can be crucial.
      • Check for splenectomy scar
      • Ask about travel, tick exposure, vaccination status, sick contacts.
    Clues that a patient may be asplenic:
    • Hemoglobinopathy (sickle cell anemia, thalassemia) 
    • Left sided abdominal surgical scar due to:
      • Hemolytic anemia (e.g. hereditary spherocytosis)
      • Trauma. Note:  S/P blunt trauma - sepsis may be less common due to the presence of accessory spleens
      • Assorted other causes: thrombocytopenia, hypersplenism, malignancy
    So, how do they present?
    • PSS is most common in the first few post-splenectomy years but can occur for decades after splenectomy.
    • Fever and rigors are the most common signs.  
    • Headache and gastrointestinal complaints (diarrhea) can be manifestations of severe pneumooccal infections and may be mistaken for gastroenteritis
    • Disseminated Intravascular Coagulation
    Suspect Organisms
    • Encapsulated bacteria (due to the production of IgM memory B cells, specially located within the spleen):   Streptococcus pneumoniae, Haemophilus influenza, and Neisseria meningitidis.  Also, Capnocytophaga canimorsus from dog bites.
    • Parasites:  
      • Malaria (Think travel to endemic areas like S.Asia, sub-Saharan Africa, etc)
      • Babesiosis - tick borne illness, especially in NY/CT and s/p RBC transfusion 
      • Ehrlichiosis - tick borne illness in the Southeast/mid-Atlantic US (1)
    • Virus:  Cytomegalovirus
    Patients with PSS deteriorate quickly, what should I do?
    • If they're septic, naturally follow the sepsis protocol.
    • Patient looks sick with a questionable/unknown vaccine history?  Give empiric antibiotics.
      • Ceftriaxone Adults: 2 g IV q12 to 24 hours, Children: 50 mg/kg IV q12 hours (1)
      • Vancomycin if S.pneumoniae penicillin resistance suspected:  Adults: 1 to 1.5 g IV q12 hours, Children: 30 mg/kg IV q12 hours (1)
    • Have a high index of suspicion for meningitis, so have a low threshold to do an LP if warranted.
    Pretty sure my patient really does just have the flu/gastroenteritis/etc, what do I do now?
    • It's recommended that asplenic patients receive prophylactic antibiotics at the onset of febrile illnesses, although this recommendation is not evidenced based.  For example, British guidelines recommend  Amoxicillin prophylaxis through adulthood.  
    • Those with adequate primary care physician coverage receive vaccines against pneumococcus, meningococcus, and haemophilus but even these are not fool proof (interestingly, over-vaccination with pneumococcal vaccine actually has a counterproductive effect on the immune system).
    • Educate. Even if they have something minor, let them know when to return to the doctor.
    References:
    1.  Pasternack, M.  Clinical features and management of sepsis in the asplenic patient.  
    2.  Di Sabatino A; Carsetti R; Corazza, G. Post-splenectomy and hyposplenic states. The Lancet378. 9785 (Jul 2-Jul 8, 2011): 86-97.
    3.  Wilkes, A, Wills, V, Smith S.  Patient knowledge of the risk of post-splenectomy sepsis.  ANZ Journal of Surgery. Volume 78, Issue 10, pages 867-870, October 2008.
    06.10.12
    by

    See one, do one, teach one…if there’s time?

    The Gist:   EM physician's perception of ED crowding may affect the number of procedures performed by trainees.  Procedures are an important part of the medical education process, especially in Emergency Medicine, but the mantra "see one, do one, teach one" may not be adequate/practical in the current clinical paradigm.  One can capitalize on the experience by understanding individual learning style, simulating procedures, and preparing for success using the resources of the medical education community.

    The paper:  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study. Atzema et al.  This isn't a must-read paper but it does raise some interesting questions.

    The study:
    • Prospective, observational study in a Level I ED with 45,000 visits/year
    • Data passively collected.  
      • Attendings (n=38) and medical student/resident trainees (n=113) recorded the procedures performed (n=804), attempted, or offered.
      • Attendings recorded procedures, that could have been done in the ED, that were deferred to consultants 
    • ED crowding was measured by two measures (1) ED attending perceived crowding (which apparently is fairly valid) and (2) ED Length of Stay (LOS)
    The results:
    • Primary Outcome not met. No statistically significant difference in number of procedures performed with a mean of 1.0 (35% of shifts) on crowded shifts and 1.25 on non-crowded shifts.
    • More procedures in the "minor" area of the ED, especially during the day shift.
    • More procedures were given away to consultants in shifts perceived as crowded by ED attendings (10.5% vs 3.4%, P = .02)
    • Most common procedures included sutures, splint/casting, fracture reductions, arterial blood gases, nerve blocks, intubations, arthrocenteses , and lumbar punctures
    • Medical students performed more procedures, per documented shift, than residents
    Why should I care about this paper?  This paper has many limitations including a small, single ED with passive data collection for less than one year.  However, I think it has some things to teach us about learning procedures..
    • Capitalize on procedures by getting familiar with them beforehand.  Many medical schools offer some instruction, but may be insufficient or remote.  
    • It's beneficial for trainees to be familiar with their own learning style.  Thrive in one-on one situations?
      • You're not alone.  This study from the BMJ demonstrated that fourth year medical students matched with one attending across shifts performed more procedures than those who had a variety of attendings. 
      • In the Atzema paper, 17.8% of shifts had more than one trainee.  This percentage is likely higher at larger teaching hospitals and could decrease the number of procedures available to a single student (although the trade-off may be larger volume), but I don't have any data to back this up other than my n=1 anecdotes. 
    • Simulation is assuming an increasingly important role and various methods have been included into the education process including simulated patients, computerized simulators, cadavers, animal simulators (ex: cricothyroidotomy training on sheep/pig tracheas), and inexpensive build-your-own simulators. 
      • In my limited experience I can vouch for the role of simulation in establishing a basic level of preparation, yet nothing comes close to the real-life scenario in which one must perform a procedure on a patient for the first time.   Perhaps the mantra, coined in Canadian Journal of Emergency Medicine, Simulation training for emergency medicine residents:  time to move forward, "see one, simulate many, do one competently, teach everyone" is the real future of learning procedures.  
    Atzema CL, Stefan RA, Saskin R, Michlik G, Austin PC.  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study.Am J Emerg Med. 2012 May 31
    06.10.12
    by

    See one, do one, teach one…if there’s time?

    The Gist:   EM physician's perception of ED crowding may affect the number of procedures performed by trainees.  Procedures are an important part of the medical education process, especially in Emergency Medicine, but the mantra "see one, do one, teach one" may not be adequate/practical in the current clinical paradigm.  One can capitalize on the experience by understanding individual learning style, simulating procedures, and preparing for success using the resources of the medical education community.

    The paper:  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study. Atzema et al.  This isn't a must-read paper but it does raise some interesting questions.

    The study:
    • Prospective, observational study in a Level I ED with 45,000 visits/year
    • Data passively collected.  
      • Attendings (n=38) and medical student/resident trainees (n=113) recorded the procedures performed (n=804), attempted, or offered.
      • Attendings recorded procedures, that could have been done in the ED, that were deferred to consultants 
    • ED crowding was measured by two measures (1) ED attending perceived crowding (which apparently is fairly valid) and (2) ED Length of Stay (LOS)
    The results:
    • Primary Outcome not met. No statistically significant difference in number of procedures performed with a mean of 1.0 (35% of shifts) on crowded shifts and 1.25 on non-crowded shifts.
    • More procedures in the "minor" area of the ED, especially during the day shift.
    • More procedures were given away to consultants in shifts perceived as crowded by ED attendings (10.5% vs 3.4%, P = .02)
    • Most common procedures included sutures, splint/casting, fracture reductions, arterial blood gases, nerve blocks, intubations, arthrocenteses , and lumbar punctures
    • Medical students performed more procedures, per documented shift, than residents
    Why should I care about this paper?  This paper has many limitations including a small, single ED with passive data collection for less than one year.  However, I think it has some things to teach us about learning procedures..
    • Capitalize on procedures by getting familiar with them beforehand.  Many medical schools offer some instruction, but may be insufficient or remote.  
    • It's beneficial for trainees to be familiar with their own learning style.  Thrive in one-on one situations?
      • You're not alone.  This study from the BMJ demonstrated that fourth year medical students matched with one attending across shifts performed more procedures than those who had a variety of attendings. 
      • In the Atzema paper, 17.8% of shifts had more than one trainee.  This percentage is likely higher at larger teaching hospitals and could decrease the number of procedures available to a single student (although the trade-off may be larger volume), but I don't have any data to back this up other than my n=1 anecdotes. 
    • Simulation is assuming an increasingly important role and various methods have been included into the education process including simulated patients, computerized simulators, cadavers, animal simulators (ex: cricothyroidotomy training on sheep/pig tracheas), and inexpensive build-your-own simulators. 
      • In my limited experience I can vouch for the role of simulation in establishing a basic level of preparation, yet nothing comes close to the real-life scenario in which one must perform a procedure on a patient for the first time.   Perhaps the mantra, coined in Canadian Journal of Emergency Medicine, Simulation training for emergency medicine residents:  time to move forward, "see one, simulate many, do one competently, teach everyone" is the real future of learning procedures.  
    Atzema CL, Stefan RA, Saskin R, Michlik G, Austin PC.  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study.Am J Emerg Med. 2012 May 31
    06.10.12
    by

    See one, do one, teach one…if there’s time?

    The Gist:   EM physician's perception of ED crowding may affect the number of procedures performed by trainees.  Procedures are an important part of the medical education process, especially in Emergency Medicine, but the mantra "see one, do one, teach one" may not be adequate/practical in the current clinical paradigm.  One can capitalize on the experience by understanding individual learning style, simulating procedures, and preparing for success using the resources of the medical education community.

    The paper:  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study. Atzema et al.  This isn't a must-read paper but it does raise some interesting questions.

    The study:
    • Prospective, observational study in a Level I ED with 45,000 visits/year
    • Data passively collected.  
      • Attendings (n=38) and medical student/resident trainees (n=113) recorded the procedures performed (n=804), attempted, or offered.
      • Attendings recorded procedures, that could have been done in the ED, that were deferred to consultants 
    • ED crowding was measured by two measures (1) ED attending perceived crowding (which apparently is fairly valid) and (2) ED Length of Stay (LOS)
    The results:
    • Primary Outcome not met. No statistically significant difference in number of procedures performed with a mean of 1.0 (35% of shifts) on crowded shifts and 1.25 on non-crowded shifts.
    • More procedures in the "minor" area of the ED, especially during the day shift.
    • More procedures were given away to consultants in shifts perceived as crowded by ED attendings (10.5% vs 3.4%, P = .02)
    • Most common procedures included sutures, splint/casting, fracture reductions, arterial blood gases, nerve blocks, intubations, arthrocenteses , and lumbar punctures
    • Medical students performed more procedures, per documented shift, than residents
    Why should I care about this paper?  This paper has many limitations including a small, single ED with passive data collection for less than one year.  However, I think it has some things to teach us about learning procedures..
    • Capitalize on procedures by getting familiar with them beforehand.  Many medical schools offer some instruction, but may be insufficient or remote.  
    • It's beneficial for trainees to be familiar with their own learning style.  Thrive in one-on one situations?
      • You're not alone.  This study from the BMJ demonstrated that fourth year medical students matched with one attending across shifts performed more procedures than those who had a variety of attendings. 
      • In the Atzema paper, 17.8% of shifts had more than one trainee.  This percentage is likely higher at larger teaching hospitals and could decrease the number of procedures available to a single student (although the trade-off may be larger volume), but I don't have any data to back this up other than my n=1 anecdotes. 
    • Simulation is assuming an increasingly important role and various methods have been included into the education process including simulated patients, computerized simulators, cadavers, animal simulators (ex: cricothyroidotomy training on sheep/pig tracheas), and inexpensive build-your-own simulators. 
      • In my limited experience I can vouch for the role of simulation in establishing a basic level of preparation, yet nothing comes close to the real-life scenario in which one must perform a procedure on a patient for the first time.   Perhaps the mantra, coined in Canadian Journal of Emergency Medicine, Simulation training for emergency medicine residents:  time to move forward, "see one, simulate many, do one competently, teach everyone" is the real future of learning procedures.  
    Atzema CL, Stefan RA, Saskin R, Michlik G, Austin PC.  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study.Am J Emerg Med. 2012 May 31
    06.04.12
    by

    Surviving Sepsis -Leveling the Playing Field via the Web

    The Gist:  Over the past decade, the Surviving Sepsis Campaign and Early Goal-Directed Therapy have altered the perception and management of sepsis  These guidelines and other crucial ED interventions change frequently, as evidenced by upcoming changes to the sepsis guidelines.  Yet, differences remain between academic and community settings in the implementation of these protocols.  With the help of EM bloggers, podcasters, and tweeters there is hope in closing the disparity!
    I've completed nearly all of my third year clerkships at two community hospitals that serve a rather large, multi-state rural catchment area (the primary hospital's ED has >57,000 visits/year).  The clinical experience is incredible and I train with outstanding, bright physicians.  As I follow podcasts, blogs, and tweets, however, I've discovered that the academic accepted "standard of care" or "best practice" often differs from community practice.  I was dismayed to find that our EDs don't use waveform capnography in intubations/procedural sedation, use ultrasound outside of FAST or vascular access, and only initiated post-arrest hypothermia within the past few months.  (Note:  I dislike referring to community and academic EDs in such a homogeneous fashion, as I'm aware there is quite a spectrum of practice, but these terms align with current discourse and seemed suitable.)

    • Assesses the results after implementation of an EGDT protocol for severe sepsis and septic shock in a community hospital (>65,000 visits/year) from 2008-2009.
    Result Highlights
    • 66/85 patients received antibiotics in first hour
    • 58/85 patients received a 2L fluid bolus in first hour (68%)
      • These patients were more likely to survive to hospital discharge
    • 79% (n=50) of patients needing vasopressors received these drugs.
    • Central line in 55/85 patients (65%, 95% CI 54-74%)
      • CVP recorded in the ED 23/85 patients (27%, 95% CI 18-36%).  
      • ScvO2 (central venous oxygen saturation) measured in 13/85 patients
    But what do these results really point to?
    • This paper found that the most invasive components (A-lines, central lines) of their resuscitation bundle were followed less frequently.  The authors concluded that this may have partially resulted from providers/staff feeling uncomfortable with these invasive procedures.  This rationalization seems odd as this community based ED also houses an EM residency program, but this is one of the most frequently cited challenges to sepsis protocol (solution = procedure hungry medical students?).    
    • Furthermore, the CVP and ScvO2 were rarely recorded, even in the presence of a central line.  The CVP has been pretty much discarded, but the ScvO2?  Did these providers get the information they needed to direct therapy in other ways?  If so, it's not documented in this article.  It's also unlikely, given that the Jones article in JAMA on lactate clearance wasn't published until 2010.
    • The fluid resuscitation goal of at least 2L of fluids in the first hour was only met in 68% of the patients.  This goal was pre-determined and didn't focus on patient response to boluses.  This is one of the seemingly easiest measures to implement and, in this particular patient population, was associated with a mortality benefit.  
    Is there a solution?
    By following EM literature and updates in an asynchronous and self-directed method, I see great alternatives/solutions to some of these issues and barriers.  For example, EMCrit's CME option could act as an incentive/inspiration for community doctors to implement cutting edge EM locally...while satisfying required CME (see real-life example on PHARM podcast below).
    • Really understand the importance of sepsis and champion excellent, early sepsis care. Parts I, II, and III from EMCrit (with Dr. Rivers himself). 
      •  I admit that I kept these videos on my iPhone/computer for quite some time before I ran out of my favorite podcasts and needed something to get me through a workout.  Sepsis just didn't seem as sexy as all of the airway and trauma talk but this definitely changed my perspective and the videos are quite good...I think I'm probably not alone in my initial attitude (especially if you look at the compliance rate with the severe sepsis protocol in the above study).  To entice other medical students there's a Septris game from Stanford.
    • Assessing Fluid Responsiveness with Ultrasound and Passive Leg Raise. Courtesy of the amazing Ultrasound Podcast parts 1 and 2.  Only have a minute and a smart phone? 
                                             
    • Lactate Clearance!  The use of non-invasive sepsis protocols that use lactate clearance instead of ScvO2 are somewhat controversial but, in any case, are better than not measuring either (referencing above study), especially in your less sick severe sepsis patients.  Dr. Scott Weingart's EMCrit site has non-invasive sepsis protocols and answers to popular questions about lactate.  I first learned about this on the excellent EMCrit Podcast 22. 
    • What about pressors?  Free Emergency Medicine Talks comes through again with Dr. Evie Marcolini's lecture on pressor choice.  She also has a talk on antibiotic choice in sepsis.  
    • Want to put it all together?  Dr. Weingart has an entire Severe Sepsis Protocol available.  
    Beyond sepsis...the podcast that kept me thinking:
    There is hope for clinician driven change in the community-based setting.
    • I found inspiration in a recent episode #16 of the PHARM podcast on delayed sequence intubation (DSI) where Dr. Rob Bryant shares his experience implementing DSI in the community setting.  He shared his DSI protocols with others via PHARM and EMCrit.  It is truly amazing to see such dissemination of knowledge and experience, flattening the playing ground for clinicians.  
    References:
    O'Neill R, Morales J, Jule M.  Early Goal-directed Therapy (EGDT) for Severe Sepsis/Septic Shock:  Which Components of Treatment are More Difficult to Implement in a Community-based Emergency Department?  Journal of Emergency Medicine.  Volume 42, Issue 5, May 2012, Pages 503-510
    06.04.12
    by

    Surviving Sepsis -Leveling the Playing Field via the Web

    The Gist:  Over the past decade, the Surviving Sepsis Campaign and Early Goal-Directed Therapy have altered the perception and management of sepsis  These guidelines and other crucial ED interventions change frequently, as evidenced by upcoming changes to the sepsis guidelines.  Yet, differences remain between academic and community settings in the implementation of these protocols.  With the help of EM bloggers, podcasters, and tweeters there is hope in closing the disparity!
    I've completed nearly all of my third year clerkships at two community hospitals that serve a rather large, multi-state rural catchment area (the primary hospital's ED has >57,000 visits/year).  The clinical experience is incredible and I train with outstanding, bright physicians.  As I follow podcasts, blogs, and tweets, however, I've discovered that the academic accepted "standard of care" or "best practice" often differs from community practice.  I was dismayed to find that our EDs don't use waveform capnography in intubations/procedural sedation, use ultrasound outside of FAST or vascular access, and only initiated post-arrest hypothermia within the past few months.  (Note:  I dislike referring to community and academic EDs in such a homogeneous fashion, as I'm aware there is quite a spectrum of practice, but these terms align with current discourse and seemed suitable.)

    • Assesses the results after implementation of an EGDT protocol for severe sepsis and septic shock in a community hospital (>65,000 visits/year) from 2008-2009.
    Result Highlights
    • 66/85 patients received antibiotics in first hour
    • 58/85 patients received a 2L fluid bolus in first hour (68%)
      • These patients were more likely to survive to hospital discharge
    • 79% (n=50) of patients needing vasopressors received these drugs.
    • Central line in 55/85 patients (65%, 95% CI 54-74%)
      • CVP recorded in the ED 23/85 patients (27%, 95% CI 18-36%).  
      • ScvO2 (central venous oxygen saturation) measured in 13/85 patients
    But what do these results really point to?
    • This paper found that the most invasive components (A-lines, central lines) of their resuscitation bundle were followed less frequently.  The authors concluded that this may have partially resulted from providers/staff feeling uncomfortable with these invasive procedures.  This rationalization seems odd as this community based ED also houses an EM residency program, but this is one of the most frequently cited challenges to sepsis protocol (solution = procedure hungry medical students?).    
    • Furthermore, the CVP and ScvO2 were rarely recorded, even in the presence of a central line.  The CVP has been pretty much discarded, but the ScvO2?  Did these providers get the information they needed to direct therapy in other ways?  If so, it's not documented in this article.  It's also unlikely, given that the Jones article in JAMA on lactate clearance wasn't published until 2010.
    • The fluid resuscitation goal of at least 2L of fluids in the first hour was only met in 68% of the patients.  This goal was pre-determined and didn't focus on patient response to boluses.  This is one of the seemingly easiest measures to implement and, in this particular patient population, was associated with a mortality benefit.  
    Is there a solution?
    By following EM literature and updates in an asynchronous and self-directed method, I see great alternatives/solutions to some of these issues and barriers.  For example, EMCrit's CME option could act as an incentive/inspiration for community doctors to implement cutting edge EM locally...while satisfying required CME (see real-life example on PHARM podcast below).
    • Really understand the importance of sepsis and champion excellent, early sepsis care. Parts I, II, and III from EMCrit (with Dr. Rivers himself). 
      •  I admit that I kept these videos on my iPhone/computer for quite some time before I ran out of my favorite podcasts and needed something to get me through a workout.  Sepsis just didn't seem as sexy as all of the airway and trauma talk but this definitely changed my perspective and the videos are quite good...I think I'm probably not alone in my initial attitude (especially if you look at the compliance rate with the severe sepsis protocol in the above study).  To entice other medical students there's a Septris game from Stanford.
    • Assessing Fluid Responsiveness with Ultrasound and Passive Leg Raise. Courtesy of the amazing Ultrasound Podcast parts 1 and 2.  Only have a minute and a smart phone? 
                                             
    • Lactate Clearance!  The use of non-invasive sepsis protocols that use lactate clearance instead of ScvO2 are somewhat controversial but, in any case, are better than not measuring either (referencing above study), especially in your less sick severe sepsis patients.  Dr. Scott Weingart's EMCrit site has non-invasive sepsis protocols and answers to popular questions about lactate.  I first learned about this on the excellent EMCrit Podcast 22. 
    • What about pressors?  Free Emergency Medicine Talks comes through again with Dr. Evie Marcolini's lecture on pressor choice.  She also has a talk on antibiotic choice in sepsis.  
    • Want to put it all together?  Dr. Weingart has an entire Severe Sepsis Protocol available.  
    Beyond sepsis...the podcast that kept me thinking:
    There is hope for clinician driven change in the community-based setting.
    • I found inspiration in a recent episode #16 of the PHARM podcast on delayed sequence intubation (DSI) where Dr. Rob Bryant shares his experience implementing DSI in the community setting.  He shared his DSI protocols with others via PHARM and EMCrit.  It is truly amazing to see such dissemination of knowledge and experience, flattening the playing ground for clinicians.  
    References:
    O'Neill R, Morales J, Jule M.  Early Goal-directed Therapy (EGDT) for Severe Sepsis/Septic Shock:  Which Components of Treatment are More Difficult to Implement in a Community-based Emergency Department?  Journal of Emergency Medicine.  Volume 42, Issue 5, May 2012, Pages 503-510
    06.04.12
    by

    Surviving Sepsis -Leveling the Playing Field via the Web

    The Gist:  Over the past decade, the Surviving Sepsis Campaign and Early Goal-Directed Therapy have altered the perception and management of sepsis  These guidelines and other crucial ED interventions change frequently, as evidenced by upcoming changes to the sepsis guidelines.  Yet, differences remain between academic and community settings in the implementation of these protocols.  With the help of EM bloggers, podcasters, and tweeters there is hope in closing the disparity!
    I've completed nearly all of my third year clerkships at two community hospitals that serve a rather large, multi-state rural catchment area (the primary hospital's ED has >57,000 visits/year).  The clinical experience is incredible and I train with outstanding, bright physicians.  As I follow podcasts, blogs, and tweets, however, I've discovered that the academic accepted "standard of care" or "best practice" often differs from community practice.  I was dismayed to find that our EDs don't use waveform capnography in intubations/procedural sedation, use ultrasound outside of FAST or vascular access, and only initiated post-arrest hypothermia within the past few months.  (Note:  I dislike referring to community and academic EDs in such a homogeneous fashion, as I'm aware there is quite a spectrum of practice, but these terms align with current discourse and seemed suitable.)

    • Assesses the results after implementation of an EGDT protocol for severe sepsis and septic shock in a community hospital (>65,000 visits/year) from 2008-2009.
    Result Highlights
    • 66/85 patients received antibiotics in first hour
    • 58/85 patients received a 2L fluid bolus in first hour (68%)
      • These patients were more likely to survive to hospital discharge
    • 79% (n=50) of patients needing vasopressors received these drugs.
    • Central line in 55/85 patients (65%, 95% CI 54-74%)
      • CVP recorded in the ED 23/85 patients (27%, 95% CI 18-36%).  
      • ScvO2 (central venous oxygen saturation) measured in 13/85 patients
    But what do these results really point to?
    • This paper found that the most invasive components (A-lines, central lines) of their resuscitation bundle were followed less frequently.  The authors concluded that this may have partially resulted from providers/staff feeling uncomfortable with these invasive procedures.  This rationalization seems odd as this community based ED also houses an EM residency program, but this is one of the most frequently cited challenges to sepsis protocol (solution = procedure hungry medical students?).    
    • Furthermore, the CVP and ScvO2 were rarely recorded, even in the presence of a central line.  The CVP has been pretty much discarded, but the ScvO2?  Did these providers get the information they needed to direct therapy in other ways?  If so, it's not documented in this article.  It's also unlikely, given that the Jones article in JAMA on lactate clearance wasn't published until 2010.
    • The fluid resuscitation goal of at least 2L of fluids in the first hour was only met in 68% of the patients.  This goal was pre-determined and didn't focus on patient response to boluses.  This is one of the seemingly easiest measures to implement and, in this particular patient population, was associated with a mortality benefit.  
    Is there a solution?
    By following EM literature and updates in an asynchronous and self-directed method, I see great alternatives/solutions to some of these issues and barriers.  For example, EMCrit's CME option could act as an incentive/inspiration for community doctors to implement cutting edge EM locally...while satisfying required CME (see real-life example on PHARM podcast below).
    • Really understand the importance of sepsis and champion excellent, early sepsis care. Parts I, II, and III from EMCrit (with Dr. Rivers himself). 
      •  I admit that I kept these videos on my iPhone/computer for quite some time before I ran out of my favorite podcasts and needed something to get me through a workout.  Sepsis just didn't seem as sexy as all of the airway and trauma talk but this definitely changed my perspective and the videos are quite good...I think I'm probably not alone in my initial attitude (especially if you look at the compliance rate with the severe sepsis protocol in the above study).  To entice other medical students there's a Septris game from Stanford.
    • Assessing Fluid Responsiveness with Ultrasound and Passive Leg Raise. Courtesy of the amazing Ultrasound Podcast parts 1 and 2.  Only have a minute and a smart phone? 
                                             
    • Lactate Clearance!  The use of non-invasive sepsis protocols that use lactate clearance instead of ScvO2 are somewhat controversial but, in any case, are better than not measuring either (referencing above study), especially in your less sick severe sepsis patients.  Dr. Scott Weingart's EMCrit site has non-invasive sepsis protocols and answers to popular questions about lactate.  I first learned about this on the excellent EMCrit Podcast 22. 
    • What about pressors?  Free Emergency Medicine Talks comes through again with Dr. Evie Marcolini's lecture on pressor choice.  She also has a talk on antibiotic choice in sepsis.  
    • Want to put it all together?  Dr. Weingart has an entire Severe Sepsis Protocol available.  
    Beyond sepsis...the podcast that kept me thinking:
    There is hope for clinician driven change in the community-based setting.
    • I found inspiration in a recent episode #16 of the PHARM podcast on delayed sequence intubation (DSI) where Dr. Rob Bryant shares his experience implementing DSI in the community setting.  He shared his DSI protocols with others via PHARM and EMCrit.  It is truly amazing to see such dissemination of knowledge and experience, flattening the playing ground for clinicians.  
    References:
    O'Neill R, Morales J, Jule M.  Early Goal-directed Therapy (EGDT) for Severe Sepsis/Septic Shock:  Which Components of Treatment are More Difficult to Implement in a Community-based Emergency Department?  Journal of Emergency Medicine.  Volume 42, Issue 5, May 2012, Pages 503-510
    05.29.12
    by

    Clinical Confidence Through Ultrasound

    The Gist:  A small (n=74), yet promising study demonstrates the perceived decision-making utility of bedside ultrasonography (U/S) in managing septic patients using IVC diameter, IVC collapsibility index, and cardiac echo.  This may prove particularly useful for those of us (students) with limited clinical experience and confidence

    The Ultrasound Podcast guys make U/S exciting and hip, yet I'm occasionally frustrated by the paucity of good data to sate the small scientific portion of my brain.  I often encounter ED physicians who don't believe that U/S really adds much to clinical practice.  If Drs. Mike Mallin and Matt Dawson can't convince them, perhaps journal articles can achieve that feat (although I remain suspect of anyone not excited about U/S after the 'name that 'stauche game' on the duo's echo episode). 

    Results:
    • Primary outcome achieved.  Treatment plan changed in 53% of the patients (n=39)
      • A change in the volume resuscitation plan in 45% of patients (n=33).
      • The decision to give pressors changed in 4 patients
    • Physicians were more confident of their assessment of deranged vital signs after viewing the U/S.
      • Sure, they're just treating numbers in this case, but this may point towards better understanding of the patient's physiological state (although what impact that makes on the patient is not addressed in this study).
    • Only 10% of treating physicians found that the U/S data didn't contribute to patient management
    The Good:
    • Prospective
    • Clinicians were initially blinded to the U/S results 
    • Demonstrates bedside U/S is do-able by clinicians.  With minimal training, clinicians were nearly always able to obtain the necessary U/S data.
    • U/S can actually change our ED management, adding to our clinical skill set and cushioning our certainty.
    The Bad:
    • Convenience sampling - no randomization
    • Lack of generalizability - Most of the patients had sepsis or severe sepsis and very few had the scary elevated lactates, one tertiary facility
    • Small cohort
    • Power? No a priori calculation, so statistical significance for the primary outcome is not evaluated
    • An average time of 138 minutes elapsed before the U/S was performed and an average of 160 minutes before the U/S was viewed by the clinician. 
      • I think this may be missing some of the critical time in sepsis...perhaps the "early" in Early Goal-Directed Therapy
      • Also, most shops I've been in obtain and interpret bedside U/S in real time
    • Changes in interventions doesn't necessarily translate into a change in patient outcomes.
    References:
    Haydar S, Moore E, Higgins G, et al.  Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decisionmaking for Septic Patients in the Emergency Department.  Annals of Emergency Medicine Article in Press, 24 May 2012.  
    05.29.12
    by

    Clinical Confidence Through Ultrasound

    The Gist:  A small (n=74), yet promising study demonstrates the perceived decision-making utility of bedside ultrasonography (U/S) in managing septic patients using IVC diameter, IVC collapsibility index, and cardiac echo.  This may prove particularly useful for those of us (students) with limited clinical experience and confidence

    The Ultrasound Podcast guys make U/S exciting and hip, yet I'm occasionally frustrated by the paucity of good data to sate the small scientific portion of my brain.  I often encounter ED physicians who don't believe that U/S really adds much to clinical practice.  If Drs. Mike Mallin and Matt Dawson can't convince them, perhaps journal articles can achieve that feat (although I remain suspect of anyone not excited about U/S after the 'name that 'stauche game' on the duo's echo episode). 

    Results:
    • Primary outcome achieved.  Treatment plan changed in 53% of the patients (n=39)
      • A change in the volume resuscitation plan in 45% of patients (n=33).
      • The decision to give pressors changed in 4 patients
    • Physicians were more confident of their assessment of deranged vital signs after viewing the U/S.
      • Sure, they're just treating numbers in this case, but this may point towards better understanding of the patient's physiological state (although what impact that makes on the patient is not addressed in this study).
    • Only 10% of treating physicians found that the U/S data didn't contribute to patient management
    The Good:
    • Prospective
    • Clinicians were initially blinded to the U/S results 
    • Demonstrates bedside U/S is do-able by clinicians.  With minimal training, clinicians were nearly always able to obtain the necessary U/S data.
    • U/S can actually change our ED management, adding to our clinical skill set and cushioning our certainty.
    The Bad:
    • Convenience sampling - no randomization
    • Lack of generalizability - Most of the patients had sepsis or severe sepsis and very few had the scary elevated lactates, one tertiary facility
    • Small cohort
    • Power? No a priori calculation, so statistical significance for the primary outcome is not evaluated
    • An average time of 138 minutes elapsed before the U/S was performed and an average of 160 minutes before the U/S was viewed by the clinician. 
      • I think this may be missing some of the critical time in sepsis...perhaps the "early" in Early Goal-Directed Therapy
    • Changes in interventions doesn't necessarily translate into a change in patient outcomes.
    References:
    Haydar S, Moore E, Higgins G, et al.  Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decisionmaking for Septic Patients in the Emergency Department.  Annals of Emergency Medicine Article in Press, 24 May 2012.  
    05.29.12
    by

    Clinical Confidence Through Ultrasound

    The Gist:  A small (n=74), yet promising study demonstrates the perceived decision-making utility of bedside ultrasonography (U/S) in managing septic patients using IVC diameter, IVC collapsibility index, and cardiac echo.  This may prove particularly useful for those of us (students) with limited clinical experience and confidence

    The Ultrasound Podcast guys make U/S exciting and hip, yet I'm occasionally frustrated by the paucity of good data to sate the small scientific portion of my brain.  I often encounter ED physicians who don't believe that U/S really adds much to clinical practice.  If Drs. Mike Mallin and Matt Dawson can't convince them, perhaps journal articles can achieve that feat (although I remain suspect of anyone not excited about U/S after the 'name that 'stauche game' on the duo's echo episode). 

    Results:
    • Primary outcome achieved.  Treatment plan changed in 53% of the patients (n=39)
      • A change in the volume resuscitation plan in 45% of patients (n=33).
      • The decision to give pressors changed in 4 patients
    • Physicians were more confident of their assessment of deranged vital signs after viewing the U/S.
      • Sure, they're just treating numbers in this case, but this may point towards better understanding of the patient's physiological state (although what impact that makes on the patient is not addressed in this study).
    • Only 10% of treating physicians found that the U/S data didn't contribute to patient management
    The Good:
    • Prospective
    • Clinicians were initially blinded to the U/S results 
    • Demonstrates bedside U/S is do-able by clinicians.  With minimal training, clinicians were nearly always able to obtain the necessary U/S data.
    • U/S can actually change our ED management, adding to our clinical skill set and cushioning our certainty.
    The Bad:
    • Convenience sampling - no randomization
    • Lack of generalizability - Most of the patients had sepsis or severe sepsis and very few had the scary elevated lactates, one tertiary facility
    • Small cohort
    • Power? No a priori calculation, so statistical significance for the primary outcome is not evaluated
    • An average time of 138 minutes elapsed before the U/S was performed and an average of 160 minutes before the U/S was viewed by the clinician. 
      • I think this may be missing some of the critical time in sepsis...perhaps the "early" in Early Goal-Directed Therapy
      • Also, most shops I've been in obtain and interpret bedside U/S in real time
    • Changes in interventions doesn't necessarily translate into a change in patient outcomes.
    References:
    Haydar S, Moore E, Higgins G, et al.  Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decisionmaking for Septic Patients in the Emergency Department.  Annals of Emergency Medicine Article in Press, 24 May 2012.  
    05.29.12
    by

    Clinical Training Wheels

    The Gist:  Emergency Medicine (EM) physicians must read patients and situations quickly and accurately.  Clinical gestalt and decision rules variably aid EM physicians in making vital decisions.  As students, the opportunity exists to build this mysterious, elusive "gestalt" during clinical exposure and to cultivate this as we grow into physician learners.  Clinical decision rules probably serve as an important stepping stone towards the boulder of clinical gestalt, but are accompanied by the potential to serve as a crutch.

    As a medical student, I always seem to finagle a decision aid like Wells', PERC, NEXUS, OTTAWA, or TIMI score into my ED patient presentation. This is my way of overcompensating for my relative clinical naivety - my lack of gestalt.  When the weight of someone's life lies in your judgement, do you trust that over an expert's calculated risk?  Sometimes, however, it seems as though this places me between a figurative rock and a hard place.  The rock symbolizing my fund of clinical knowledge and patient evaluation, whereas the hard place symbolizes the decision of utilizing a clinical decision rule, even if I know it's not that great or I know I'm solely employing the decision aid as a security blanket.  

    What is "clinical gestalt?"
    • A gut instinct, or overall analysis, cultivated by personal experience and established through history and physical.  
    • Evidence suggests that additional years of clinical experience improves ones overall clinical assessment of a patient.  A 2005 study in Chest demonstrated a trend towards increased accuracy in diagnosis of PE in more experienced clinicians, although this did not reach statistical significance.   Strange how that works, eh?  We get better with practice, maybe.  
    What about clinical decision rules?
    • As a student, I innately love these although I know they're fraught with problems and validity issues.  They build a framework and a guideline to substitute for the judgment and gestalt I have not yet cultivated.  The rules seem to back up and quantify the components that might comprise an experienced clinician's gestalt - and it seems there's a rule for nearly everything.
    • Decision rules allow one to assess various aspects of a patient, add up a few numbers (typically countable on two hands), and provide us with a clean, black and white statistic, such as pre-test probability.  Here are calculators for popular PE rules:  the Wells' Criteria and, for low risk patients, the Pulmonary Embolism Rule Out Criteria (PERC).  
    • Offsets risk.  These rules may give a physician a safety net of scientific evidence what they've already surmised with their gestalt.  For example, the Canadian Head CT rule could have a promising impact on reducing the number of CT scans in minor head injury.
    • Clinical decision rules represent a wide variety of levels of evidence, depending partially on the validation of the rule, internally or externally.  Perhaps the numbers aren't as clean as they seem.  
    Clinical decision rules seem easy, shouldn't we just use those?
    • As algorithms, there's the possibility that clinicians may become too dependent on decision rules as opposed to continuing to develop and utilize clinical reasoning and thought.
    • The rules turn out to be nowhere near perfect and the external validation studies rarely seem to concur with the original derivations.  The San Francisco Syncope Rule serves an excellent example of a failure of a decision rule.  The validation studies for this rule, hoping to identify all serious outcomes within 7 days of the presenting syncopal episode, had sensitivities in the 79-80% range, far below an acceptable percentage for ED purposes and well below the touted 96% sensitivity in the original study (1,2).  Of note, clinicians were 100% sensitive in meeting the primary endpoint the rule was designed to detect (3).  
      • Affected by variations in disease prevalence, variable application of the rules by clinicians, and instability of the model from which the rule was derived.
    • Clinical decision rules are not uniformly agreed upon because they exist as a tool, rather than a rule (despite the nomenclature).  
      • This debate between Dr. David Newman and Dr. Scott Weingart is exemplary in demonstrating disagreement between excellent physicians over decision rules in PE.
      • Utilization of these rules could be problematic when it conflicts with a less measurable and quantifiable measure such as clinical gestalt, particularly in the setting of a highly litigious health care climate.
    • Wide variation in use and familiarity of rules exists between academic and community medicine practices.  
    So what do we do?
    • Use a mixture and encourage this practice.  This 2003 analysis in JAMA demonstrated "similar" outcomes in clinicians who used gestalt versus those who used clinical decision rules.
      • This algorithm for PE from EMCrit demonstrates an integration of gestalt with clinical decision rules (where clinical gestalt trumps everything).
    • Historically, EM physicians (lumped together as a group), have pretty good clinical gestalt so use clinical encounters to cultivate away!  
    • As a student, my inclination is that decision rules serve as the building blocks for gestalt, a way of beginning to form those pattern recognition skills.  Additionally, they may prevent us from harming patients (or planning to, before an attending kindly guides us in a more appropriate direction).  Yet, we must cast off our training wheels at some point.
    • Continue the dialogue regarding gestalt and decision rules so that both become better.  See Twitter for banter from the Annual Scientific Meeting of the College of Intensive Care medicine (#CICMASM) where one tweeter stated, "NICE guidelines favor esophageal Doppler, grey haired intensivists favor bedside thought + clinical exam." 
    References:
    1.  Sun  BC, Mangione  CM, Merchant  G, et al.  External validation of the San Francisco Syncope Rule.  Ann Emerg Med. 2007;49(4):420-427. 
    2.  Cosgriff  TM, Kelly  AM, Kerr  D.  External validation of the San Francisco Syncope Rule in the Australian context. CJEM.  2007;9(3):157-161.
    3.  Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52(2):151-159.
    05.29.12
    by

    Clinical Training Wheels

    The Gist:  Emergency Medicine (EM) physicians must read patients and situations quickly and accurately.  Clinical gestalt and decision rules variably aid EM physicians in making vital decisions.  As students, the opportunity exists to build this mysterious, elusive "gestalt" during clinical exposure and to cultivate this as we grow into physician learners.  Clinical decision rules probably serve as an important stepping stone towards the boulder of clinical gestalt, but are accompanied by the potential to serve as a crutch.

    As a medical student, I always seem to finagle a decision aid like Wells', PERC, NEXUS, OTTAWA, or TIMI score into my ED patient presentation. This is my way of overcompensating for my relative clinical naivety - my lack of gestalt.  When the weight of someone's life lies in your judgement, do you trust that over an expert's calculated risk?  Sometimes, however, it seems as though this places me between a figurative rock and a hard place.  The rock symbolizing my fund of clinical knowledge and patient evaluation, whereas the hard place symbolizes the decision of utilizing a clinical decision rule, even if I know it's not that great or I know I'm solely employing the decision aid as a security blanket.  

    What is "clinical gestalt?"
    • A gut instinct, or overall analysis, cultivated by personal experience and established through history and physical.  
    • Evidence suggests that additional years of clinical experience improves ones overall clinical assessment of a patient.  A 2005 study in Chest demonstrated a trend towards increased accuracy in diagnosis of PE in more experienced clinicians, although this did not reach statistical significance.   Strange how that works, eh?  We get better with practice, maybe.  
    What about clinical decision rules?
    • As a student, I innately love these although I know they're fraught with problems and validity issues.  They build a framework and a guideline to substitute for the judgment and gestalt I have not yet cultivated.  The rules seem to back up and quantify the components that might comprise an experienced clinician's gestalt - and it seems there's a rule for nearly everything.
    • Decision rules allow one to assess various aspects of a patient, add up a few numbers (typically countable on two hands), and provide us with a clean, black and white statistic, such as pre-test probability.  Here are calculators for popular PE rules:  the Wells' Criteria and, for low risk patients, the Pulmonary Embolism Rule Out Criteria (PERC).  
    • Offsets risk.  These rules may give a physician a safety net of scientific evidence what they've already surmised with their gestalt.  For example, the Canadian Head CT rule could have a promising impact on reducing the number of CT scans in minor head injury.
    • Clinical decision rules represent a wide variety of levels of evidence, depending partially on the validation of the rule, internally or externally.  Perhaps the numbers aren't as clean as they seem.  
    Clinical decision rules seem easy, shouldn't we just use those?
    • As algorithms, there's the possibility that clinicians may become too dependent on decision rules as opposed to continuing to develop and utilize clinical reasoning and thought.
    • The rules turn out to be nowhere near perfect and the external validation studies rarely seem to concur with the original derivations.  The San Francisco Syncope Rule serves an excellent example of a failure of a decision rule.  The validation studies for this rule, hoping to identify all serious outcomes within 7 days of the presenting syncopal episode, had sensitivities in the 79-80% range, far below an acceptable percentage for ED purposes and well below the touted 96% sensitivity in the original study (1,2).  Of note, clinicians were 100% sensitive in meeting the primary endpoint the rule was designed to detect (3).  
      • Affected by variations in disease prevalence, variable application of the rules by clinicians, and instability of the model from which the rule was derived.
    • Clinical decision rules are not uniformly agreed upon because they exist as a tool, rather than a rule (despite the nomenclature).  
      • This debate between Dr. David Newman and Dr. Scott Weingart is exemplary in demonstrating disagreement between excellent physicians over decision rules in PE.
      • Utilization of these rules could be problematic when it conflicts with a less measurable and quantifiable measure such as clinical gestalt, particularly in the setting of a highly litigious health care climate.
    • Wide variation in use and familiarity of rules exists between academic and community medicine practices.  
    So what do we do?
    • Use a mixture and encourage this practice.  This 2003 analysis in JAMA demonstrated "similar" outcomes in clinicians who used gestalt versus those who used clinical decision rules.
      • This algorithm for PE from EMCrit demonstrates an integration of gestalt with clinical decision rules (where clinical gestalt trumps everything).
    • Historically, EM physicians (lumped together as a group), have pretty good clinical gestalt so use clinical encounters to cultivate away!  
    • As a student, my inclination is that decision rules serve as the building blocks for gestalt, a way of beginning to form those pattern recognition skills.  Additionally, they may prevent us from harming patients (or planning to, before an attending kindly guides us in a more appropriate direction).  Yet, we must cast off our training wheels at some point.
    • Continue the dialogue regarding gestalt and decision rules so that both become better.  See Twitter for banter from the Annual Scientific Meeting of the College of Intensive Care medicine (#CICMASM) where one tweeter stated, "NICE guidelines favor esophageal Doppler, grey haired intensivists favor bedside thought + clinical exam." 
    References:
    1.  Sun  BC, Mangione  CM, Merchant  G, et al.  External validation of the San Francisco Syncope Rule.  Ann Emerg Med. 2007;49(4):420-427. 
    2.  Cosgriff  TM, Kelly  AM, Kerr  D.  External validation of the San Francisco Syncope Rule in the Australian context. CJEM.  2007;9(3):157-161.
    3.  Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52(2):151-159.
    05.29.12
    by

    Clinical Training Wheels

    The Gist:  Emergency Medicine (EM) physicians must read patients and situations quickly and accurately.  Clinical gestalt and decision rules variably aid EM physicians in making vital decisions.  As students, the opportunity exists to build this mysterious, elusive "gestalt" during clinical exposure and to cultivate this as we grow into physician learners.  Clinical decision rules probably serve as an important stepping stone towards the boulder of clinical gestalt, but are accompanied by the potential to serve as a crutch.

    As a medical student, I always seem to finagle a decision aid like Wells', PERC, NEXUS, OTTAWA, or TIMI score into my ED patient presentation. This is my way of overcompensating for my relative clinical naivety - my lack of gestalt.  When the weight of someone's life lies in your judgement, do you trust that over an expert's calculated risk?  Sometimes, however, it seems as though this places me between a figurative rock and a hard place.  The rock symbolizing my fund of clinical knowledge and patient evaluation, whereas the hard place symbolizes the decision of utilizing a clinical decision rule, even if I know it's not that great or I know I'm solely employing the decision aid as a security blanket.  

    What is "clinical gestalt?"
    • A gut instinct, or overall analysis, cultivated by personal experience and established through history and physical.  
    • Evidence suggests that additional years of clinical experience improves ones overall clinical assessment of a patient.  A 2005 study in Chest demonstrated a trend towards increased accuracy in diagnosis of PE in more experienced clinicians, although this did not reach statistical significance.   Strange how that works, eh?  We get better with practice, maybe.  
    What about clinical decision rules?
    • As a student, I innately love these although I know they're fraught with problems and validity issues.  They build a framework and a guideline to substitute for the judgment and gestalt I have not yet cultivated.  The rules seem to back up and quantify the components that might comprise an experienced clinician's gestalt - and it seems there's a rule for nearly everything.
    • Decision rules allow one to assess various aspects of a patient, add up a few numbers (typically countable on two hands), and provide us with a clean, black and white statistic, such as pre-test probability.  Here are calculators for popular PE rules:  the Wells' Criteria and, for low risk patients, the Pulmonary Embolism Rule Out Criteria (PERC).  
    • Offsets risk.  These rules may give a physician a safety net of scientific evidence what they've already surmised with their gestalt.  For example, the Canadian Head CT rule could have a promising impact on reducing the number of CT scans in minor head injury.
    • Clinical decision rules represent a wide variety of levels of evidence, depending partially on the validation of the rule, internally or externally.  Perhaps the numbers aren't as clean as they seem.  
    Clinical decision rules seem easy, shouldn't we just use those?
    • As algorithms, there's the possibility that clinicians may become too dependent on decision rules as opposed to continuing to develop and utilize clinical reasoning and thought.
    • The rules turn out to be nowhere near perfect and the external validation studies rarely seem to concur with the original derivations.  The San Francisco Syncope Rule serves an excellent example of a failure of a decision rule.  The validation studies for this rule, hoping to identify all serious outcomes within 7 days of the presenting syncopal episode, had sensitivities in the 79-80% range, far below an acceptable percentage for ED purposes and well below the touted 96% sensitivity in the original study (1,2).  Of note, clinicians were 100% sensitive in meeting the primary endpoint the rule was designed to detect (3).  
      • Affected by variations in disease prevalence, variable application of the rules by clinicians, and instability of the model from which the rule was derived.
    • Clinical decision rules are not uniformly agreed upon because they exist as a tool, rather than a rule (despite the nomenclature).  
      • This debate between Dr. David Newman and Dr. Scott Weingart is exemplary in demonstrating disagreement between excellent physicians over decision rules in PE.
      • Utilization of these rules could be problematic when it conflicts with a less measurable and quantifiable measure such as clinical gestalt, particularly in the setting of a highly litigious health care climate.
    • Wide variation in use and familiarity of rules exists between academic and community medicine practices.  
    So what do we do?
    • Use a mixture and encourage this practice.  This 2003 analysis in JAMA demonstrated "similar" outcomes in clinicians who used gestalt versus those who used clinical decision rules.
      • This algorithm for PE from EMCrit demonstrates an integration of gestalt with clinical decision rules (where clinical gestalt trumps everything).
    • Historically, EM physicians (lumped together as a group), have pretty good clinical gestalt so use clinical encounters to cultivate away!  
    • As a student, my inclination is that decision rules serve as the building blocks for gestalt, a way of beginning to form those pattern recognition skills.  Additionally, they may prevent us from harming patients (or planning to, before an attending kindly guides us in a more appropriate direction).  Yet, we must cast off our training wheels at some point.
    • Continue the dialogue regarding gestalt and decision rules so that both become better.  See Twitter for banter from the Annual Scientific Meeting of the College of Intensive Care medicine (#CICMASM) where one tweeter stated, "NICE guidelines favor esophageal Doppler, grey haired intensivists favor bedside thought + clinical exam." 
    References:
    1.  Sun  BC, Mangione  CM, Merchant  G, et al.  External validation of the San Francisco Syncope Rule.  Ann Emerg Med. 2007;49(4):420-427. 
    2.  Cosgriff  TM, Kelly  AM, Kerr  D.  External validation of the San Francisco Syncope Rule in the Australian context. CJEM.  2007;9(3):157-161.
    3.  Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52(2):151-159.
    05.24.12
    by

    Not Always Evident – A Self-Guided Approach to Evidence

    The Gist:  This isn't a sexy topic, but evidenced based medicine plays a critical role in EM and it's crucial to be able to interpret and apply data.  Rather than glancing barely beyond the abstract, check out some quick tools that demonstrate key skills to help one piece together the influx of new data in a meaningful, interesting, and quick way.  Use Emergency Medicine Literature of Note as the springboard - it takes minimal time and proffers great returns.  It's really not as dry or time consuming as you may think.

    In medical school, we briefly covered bare bones epidemiology in preparation for board exams, but had nothing to equip us to critique articles and data.  That was fine with me until we spent two classes in one of my Master of Public Health courses on article/study analysis.  I was amazed at what the data, buried in complex inclusion criteria and analyses, actually concluded.  You can find a study to prove absolutely anything.  Perhaps many medical students glean these skills in college; however, as a Middle Eastern History major, my research was on Orientalism and gender.  I acquired an affinity for Turkish coffee, but little understanding of things like study design, confounders, absolute risk reduction, and subgroup analysis.  I'm still climbing the learning curve in this arena but seriously, if I can learn and be intrigued by this stuff, then absolutely anyone can.


    Not convinced that analyzing and interpreting medical literature is important?
    • It's now tested on the USMLE Step 2 in practical application format.
    • Save your patients.  Medicine changes constantly.  As a result, I've encountered many attendings who use students as a means of staying current.  Apply the things you learn from the literature (ex: on Family Medicine, I championed antibiotic stewardship and the new cervical cancer screening guidelines.  Saving the world, one less pap smear and one less antibiotic prescription at a time).
    • Most medical students keep the touted evidence based medicine database, UpToDate, at our fingertips.  Sometimes, however, the evidence supporting these articles is actually pretty terrible. For example, UpToDate's overview of hyperkalemia management cites the reduction of potassium through the use of sodium polysterene resins like Kayexelate.  The actual evidence is disguised in the parenthetical reference to the journal article from 1961, sans abstract and featuring seven subjects.  Underpowered? Methodologically flawed?
    FUNdamentals. Here's a basic tutorial created by UNC and Duke (Go Tar Heels!).  Basic questions I try to assess with each study:
    • What's the primary outcome measurement?  Was it met?
    • Was there a good control group?
    • Is the study sample reflective of the population? Who was left out of the study?  How was sampling conducted?
    • Are the methods clear?  Lots of loss to follow up?
    • Are there confounders?
    • Do the results apply to other people/populations?
    • Did what was measured actually mean anything to the patient?
    "But this takes forever."  It can be overwhelming to think about critiquing articles, taking care of patients, cheering on our sports team, studying for boards, and pursuing a personal life.  Fortunately, there are individuals skilled in this endeavor that one can simultaneously learn from and emulate while staying current with medical literature. Here's how I'm trying to improve my analytic skills - lLearn from the masters. Note: It's neat to read the article in question before checking these opinions/interpretations and see how the analysis matches up.
    • Check out Dr. Ryan Radecki's blog EM Lit of Note.  Dr. Radecki gives a concise, insightful, readable synopsis of popular literature several times each week.  These critiques are easy to read and, although colored by his own opinion, provide insight into important pitfalls and clinical implications of these studies. 
    • The website theNNT.com is incredibly handy site that assesses common treatments and diagnostic tests by the Number Needed to Treat (NNT) to prevent a bad outcome and the number of patients harmed in that same process.  Begin by checking the NNT for various standards in medical practice when you're so inclined, take a gander at the section where they describe how they calculated the numbers.  Like most things in medicine, these numbers aren't universally agreed upon, but it's a neat, helpful tool.
    • Clinical Conversations from JournalWatch is a weekly, brief, ~10 minute podcast reviewing one article in press, often with the article's author. 
    • Learning Link Clinical Update (AAFP) is a ~25 minute podcast twice each month reviewing high-impact articles and interpreting what they mean for clinical practice.
    • Dr. Richard Lehman's Journal Review.  Dr. Lehman quickly highlights a few articles from the world's leading medical journals, providing his opinion on these studies and/or the implications that lie therein.
    • SMARTEM with Dr. David Newman and Dr. Ashley Shreves.  This duo takes deep dives into the literature, from which one can absorb an incredible amount about how to deconstruct studies.  These are dense and worth more than one listen but they're well done and interesting.
    • Check out Twitter.  In this forum there's amazing international dialogue regarding medical literature.  Insightful, fiery, and humorous.  In fact, one of my favorite conversations began with the following tweet after the NEJM published a study on azithromycin and CV disease "just f***in great ."
    • The Wakefield paper on autism captured my interest and ire.  Check out Retraction Watch, a blog dedicated to exploring retracted scientific papers.
    • R&R in the Fast Lane can be used to briefly see what what other physicians think is important, practice changing, weird, or ridiculous in the literature
    Have a longer attention span?  Not an audio or immersion style learner? 
    • The University of Illinois - Chicago has this site, which has tutorials on evidenced based medicine, sorting through literature, and succinct instructions on how to use PubMed and other sites.
    • The Annals of Emergency Medicine has a site specifically geared to help the EM community translate evidence into clinical practice.
    • This article has a basic run down of the basics, if you're the reading type.  
    I know, dull..but important.
    05.24.12
    by

    Not Always Evident – A Self-Guided Approach to Evidence

    The Gist:  This isn't a sexy topic, but evidenced based medicine plays a critical role in EM and it's crucial to be able to interpret and apply data.  Rather than glancing barely beyond the abstract, check out some quick tools that demonstrate key skills to help one piece together the influx of new data in a meaningful, interesting, and quick way.  Use Emergency Medicine Literature of Note as the springboard - it takes minimal time and proffers great returns.  It's really not as dry or time consuming as you may think.

    In medical school, we briefly covered bare bones epidemiology in preparation for board exams, but had nothing to equip us to critique articles and data.  That was fine with me until we spent two classes in one of my Master of Public Health courses on article/study analysis.  I was amazed at what the data, buried in complex inclusion criteria and analyses, actually concluded.  You can find a study to prove absolutely anything.  Perhaps many medical students glean these skills in college; however, as a Middle Eastern History major, my research was on Orientalism and gender.  I acquired an affinity for Turkish coffee, but little understanding of things like study design, confounders, absolute risk reduction, and subgroup analysis.  I'm still climbing the learning curve in this arena but seriously, if I can learn and be intrigued by this stuff, then absolutely anyone can.


    Not convinced that analyzing and interpreting medical literature is important?
    • It's now tested on the USMLE Step 2 in practical application format.
    • Save your patients.  Medicine changes constantly.  As a result, I've encountered many attendings who use students as a means of staying current.  Apply the things you learn from the literature (ex: on Family Medicine, I championed antibiotic stewardship and the new cervical cancer screening guidelines.  Saving the world, one less pap smear and one less antibiotic prescription at a time).
    • Most medical students keep the touted evidence based medicine database, UpToDate, at our fingertips.  Sometimes, however, the evidence supporting these articles is actually pretty terrible. For example, UpToDate's overview of hyperkalemia management cites the reduction of potassium through the use of sodium polysterene resins like Kayexelate.  The actual evidence is disguised in the parenthetical reference to the journal article from 1961, sans abstract and featuring seven subjects.  Underpowered? Methodologically flawed?
    FUNdamentals. Here's a basic tutorial created by UNC and Duke (Go Tar Heels!).  Basic questions I try to assess with each study:
    • What's the primary outcome measurement?  Was it met?
    • Was there a good control group?
    • Is the study sample reflective of the population? Who was left out of the study?  How was sampling conducted?
    • Are the methods clear?  Lots of loss to follow up?
    • Are there confounders?
    • Do the results apply to other people/populations?
    • Did what was measured actually mean anything to the patient?
    "But this takes forever."  It can be overwhelming to think about critiquing articles, taking care of patients, cheering on our sports team, studying for boards, and pursuing a personal life.  Fortunately, there are individuals skilled in this endeavor that one can simultaneously learn from and emulate while staying current with medical literature. Here's how I'm trying to improve my analytic skills - lLearn from the masters. Note: It's neat to read the article in question before checking these opinions/interpretations and see how the analysis matches up.
    • Check out Dr. Ryan Radecki's blog EM Lit of Note.  Dr. Radecki gives a concise, insightful, readable synopsis of popular literature several times each week.  These critiques are easy to read and, although colored by his own opinion, provide insight into important pitfalls and clinical implications of these studies. 
    • The website theNNT.com is incredibly handy site that assesses common treatments and diagnostic tests by the Number Needed to Treat (NNT) to prevent a bad outcome and the number of patients harmed in that same process.  Begin by checking the NNT for various standards in medical practice when you're so inclined, take a gander at the section where they describe how they calculated the numbers.  Like most things in medicine, these numbers aren't universally agreed upon, but it's a neat, helpful tool.
    • Clinical Conversations from JournalWatch is a weekly, brief, ~10 minute podcast reviewing one article in press, often with the article's author. 
    • Learning Link Clinical Update (AAFP) is a ~25 minute podcast twice each month reviewing high-impact articles and interpreting what they mean for clinical practice.
    • Dr. Richard Lehman's Journal Review.  Dr. Lehman quickly highlights a few articles from the world's leading medical journals, providing his opinion on these studies and/or the implications that lie therein.
    • SMARTEM with Dr. David Newman and Dr. Ashley Shreves.  This duo takes deep dives into the literature, from which one can absorb an incredible amount about how to deconstruct studies.  These are dense and worth more than one listen but they're well done and interesting.
    • Check out Twitter.  In this forum there's amazing international dialogue regarding medical literature.  Insightful, fiery, and humorous.  In fact, one of my favorite conversations began with the following tweet after the NEJM published a study on azithromycin and CV disease "just f***in great ."
    • The Wakefield paper on autism captured my interest and ire.  Check out Retraction Watch, a blog dedicated to exploring retracted scientific papers.
    • R&R in the Fast Lane can be used to briefly see what what other physicians think is important, practice changing, weird, or ridiculous in the literature
    Have a longer attention span?  Not an audio or immersion style learner? 
    • The University of Illinois - Chicago has this site, which has tutorials on evidenced based medicine, sorting through literature, and succinct instructions on how to use PubMed and other sites.
    • The Annals of Emergency Medicine has a site specifically geared to help the EM community translate evidence into clinical practice.
    • This article has a basic run down of the basics, if you're the reading type.  
    I know, dull..but important.
    05.24.12
    by

    Not Always Evident – A Self-Guided Approach to Evidence

    The Gist:  This isn't a sexy topic, but evidenced based medicine plays a critical role in EM and it's crucial to be able to interpret and apply data.  Rather than glancing barely beyond the abstract, check out some quick tools that demonstrate key skills to help one piece together the influx of new data in a meaningful, interesting, and quick way.  Use Emergency Medicine Literature of Note as the springboard - it takes minimal time and proffers great returns.  It's really not as dry or time consuming as you may think.

    In medical school, we briefly covered bare bones epidemiology in preparation for board exams, but had nothing to equip us to critique articles and data.  That was fine with me until we spent two classes in one of my Master of Public Health courses on article/study analysis.  I was amazed at what the data, buried in complex inclusion criteria and analyses, actually concluded.  You can find a study to prove absolutely anything.  Perhaps many medical students glean these skills in college; however, as a Middle Eastern History major, my research was on Orientalism and gender.  I acquired an affinity for Turkish coffee, but little understanding of things like study design, confounders, absolute risk reduction, and subgroup analysis.  I'm still climbing the learning curve in this arena but seriously, if I can learn and be intrigued by this stuff, then absolutely anyone can.


    Not convinced that analyzing and interpreting medical literature is important?
    • It's now tested on the USMLE Step 2 in practical application format.
    • Save your patients.  Medicine changes constantly.  As a result, I've encountered many attendings who use students as a means of staying current.  Apply the things you learn from the literature (ex: on Family Medicine, I championed antibiotic stewardship and the new cervical cancer screening guidelines.  Saving the world, one less pap smear and one less antibiotic prescription at a time).
    • Most medical students keep the touted evidence based medicine database, UpToDate, at our fingertips.  Sometimes, however, the evidence supporting these articles is actually pretty terrible. For example, UpToDate's overview of hyperkalemia management cites the reduction of potassium through the use of sodium polysterene resins like Kayexelate.  The actual evidence is disguised in the parenthetical reference to the journal article from 1961, sans abstract and featuring seven subjects.  Underpowered? Methodologically flawed?
    FUNdamentals. Here's a basic tutorial created by UNC and Duke (Go Tar Heels!).  Basic questions I try to assess with each study:
    • What's the primary outcome measurement?  Was it met?
    • Was there a good control group?
    • Is the study sample reflective of the population? Who was left out of the study?  How was sampling conducted?
    • Are the methods clear?  Lots of loss to follow up?
    • Are there confounders?
    • Do the results apply to other people/populations?
    • Did what was measured actually mean anything to the patient?
    "But this takes forever."  It can be overwhelming to think about critiquing articles, taking care of patients, cheering on our sports team, studying for boards, and pursuing a personal life.  Fortunately, there are individuals skilled in this endeavor that one can simultaneously learn from and emulate while staying current with medical literature. Here's how I'm trying to improve my analytic skills - lLearn from the masters. Note: It's neat to read the article in question before checking these opinions/interpretations and see how the analysis matches up.
    • Check out Dr. Ryan Radecki's blog EM Lit of Note.  Dr. Radecki gives a concise, insightful, readable synopsis of popular literature several times each week.  These critiques are easy to read and, although colored by his own opinion, provide insight into important pitfalls and clinical implications of these studies. 
    • The website theNNT.com is incredibly handy site that assesses common treatments and diagnostic tests by the Number Needed to Treat (NNT) to prevent a bad outcome and the number of patients harmed in that same process.  Begin by checking the NNT for various standards in medical practice when you're so inclined, take a gander at the section where they describe how they calculated the numbers.  Like most things in medicine, these numbers aren't universally agreed upon, but it's a neat, helpful tool.
    • Clinical Conversations from JournalWatch is a weekly, brief, ~10 minute podcast reviewing one article in press, often with the article's author. 
    • Learning Link Clinical Update (AAFP) is a ~25 minute podcast twice each month reviewing high-impact articles and interpreting what they mean for clinical practice.
    • Dr. Richard Lehman's Journal Review.  Dr. Lehman quickly highlights a few articles from the world's leading medical journals, providing his opinion on these studies and/or the implications that lie therein.
    • SMARTEM with Dr. David Newman and Dr. Ashley Shreves.  This duo takes deep dives into the literature, from which one can absorb an incredible amount about how to deconstruct studies.  These are dense and worth more than one listen but they're well done and interesting.
    • Check out Twitter.  In this forum there's amazing international dialogue regarding medical literature.  Insightful, fiery, and humorous.  In fact, one of my favorite conversations began with the following tweet after the NEJM published a study on azithromycin and CV disease "just f***in great ."
    • The Wakefield paper on autism captured my interest and ire.  Check out Retraction Watch, a blog dedicated to exploring retracted scientific papers.
    • R&R in the Fast Lane can be used to briefly see what what other physicians think is important, practice changing, weird, or ridiculous in the literature
    Have a longer attention span?  Not an audio or immersion style learner? 
    • The University of Illinois - Chicago has this site, which has tutorials on evidenced based medicine, sorting through literature, and succinct instructions on how to use PubMed and other sites.
    • The Annals of Emergency Medicine has a site specifically geared to help the EM community translate evidence into clinical practice.
    • This article has a basic run down of the basics, if you're the reading type.  
    I know, dull..but important.
    05.21.12
    by

    I See Right Through You – Intro to EM Ultrasound

    The Gist:  Within the Emergency Medicine (EM) realm, ultrasound (US) is gaining an incredible amount of momentum.  Once relegated solely to use in FAST (focused assessment with sonography for trauma) exams, obstetrics, and placement of vascular catheters, US use and its application are growing in EM.  Keep up by using US often, getting this application, and learning from these guys.

    Radiology is boring so why should I care about US?  It takes too much time.  They're just going to get a CT anyways.
    • Surprisingly, I occasionally let my "inner nerd" shine.  My discovery of EM US has highlighted this personality attribute, typically when discussing a patient's workup and my suggestion for an ultrasound is met with a scoff or a blank look.  I launch into a giddy medical student frenzy citing recent papers on the risks of radiation and efficiency of bedside US.  This is exciting stuff!  
      • Both the medical and lay communities are exploring the burgeoning use of CT scans and the costs and risks associated therein, particularly in younger patients.  Thus, as a no-radiation study, US is gaining ground as a first-line imaging modality.  As a public health student, it's easy to get excited about the ways in which bedside US can help achieve better patient outcomes.
    • Immediate gratification.  Medical students seemingly live for the pursuit of test results.  With US, one gets immediate feedback, readily allowing appropriate treatment and disposition.
    • Bedside US can be quick.  Many challenge this point, but data are accumulating to suggest that ED length of stay (LOS) can actually decrease with bedside ultrasound by EM physicians. 
      • Over a decade ago, a retrospective chart review demonstrated that patients with RUQ pain receiving a gallbladder US by EM residents had a significantly reduced LOS compared with those who had scans in radiology (1).
      • Recently, a twitter update alerted me to a study at Sinai where ED US in appendicitis was associated with a decreased LOS  (2). 
      • US for deep vein thrombosis by EM physicians also apparently decreases LOS (3)
    • The CT scanner is often clogged, probably because between 1/8 and 1/14 patients presenting to the ED in the United States receives a CT scan (4).
    But, US is so "operator dependent" and too "technical" for mere students.
    • These excuses began this blog in the inaugural post, "Ultrasound for Dummies," a tidbit one might never know due to the tortuous and tangential nature of this blog.  In reality, increased emphasis on excellent US training in the EM curriculum is proving the opposite of these common refrains - EM physicians can perform adequate and timely US.  EBMedicine has an excellent summary of the evidence behind ED US.
    • The key lies in hands-on practice...even more reason to get hooked early.
    • If the US is equivocal, you may still send the patient to the CT scanner (or perform other imaging/tests).  
    Perhaps I'm now slightly intrigued by US...where do I start?
    • The absolute first place to start is with the brainchild of Dr. Mike Mallin and Dr. Matt Dawson, Ultrasound Podcast where they "Make Horrible Doctors Decent and Good Doctors Great." (I wonder what they do to medical students?)
      • This podcast is entertaining, thorough, and emphasizes the practical application of US in the ED.  Warning: (1) A few portions of the cardiac US lectures are dense and technical - bear through this and keep the podcasts on your phone for future reference (2) Don't listen to this podcast whilst running or driving (the video is key and this could be dangerous) (3) Listening to these podcasts on the elliptical in a public space may be detrimental to your image, as they are prone to make one burst into a fit of laughter.
      • Although openly biased, the podcasts provide literature sources for the techniques presented and highlight aspects for future research.
      • The free 1 Minute Ultrasound application for iPhone and Droid makes US accessible and quick in the ED.
    • UC-Irvine has good, instructive video lectures downloadable via iTunes
    • Many EM programs offer US electives for visiting medical students.  I can't comment on the quality of these yet, but I will in the next few months.
    • Society of Academic Emergency Medicine (SAEM) has narrated lectures on a few techniques
    Looking for a manual-style breakdown of various ultrasound procedures?
    But, nobody around here ultrasounds...anything!
    • Ultrasound each other.  The EM interest group at my medical school set up some time in the Vascular Sonography program's lab.  Students and instructors from that program were available to introduce us to the world of US.  
      • Apparently, extra-firm tofu also works well for a delicious and inexpensive ultrasound simulation (reference #SAEM12).
    • Ultrasound is an intellectual epidemic in EM.  However, if you just can't wait until your time in the ED, one can manage to find utility for ultrasound in nearly any medical field.
      • For example, on a nephrology rotation, I somehow managed to introduce people to bedside IVC ultrasound and they got excited about doing it.  
    • EDs have variable access to bedside US.  Tactfully advocate for improved patient care and outcomes by demonstrating the amazingness of US through the "1 Minute Ultrasound" application or by pandering to an outcome they're passionate about (ex: ED LOS).
    Your charm and subtle enthusiasm for ultrasound piqued my interest in US...I want more! (Alternatively:  Supplement to an EM US elective)
    • Add the SinaiEM.us blog to GoogleReader
    • Case-based learner? Check out a plethora of neat case based videos.
    • Ultrasoundvillage.com has an amazing image library, sort-able by organ system
    • Search the web for EM US fellowship programs.  Many of these programs have extensive links and resources available, similar to the University of Arizona's list that provide excellent education.
    • There are also excellent blog posts at takeokun.com
    • The Stanford 25 take on bedside ultrasound, with various monotonic modules from USC. 
    • Initiate dialogue with other specialists, students, and attendings on the utility and meaning of EM US.  An easy way to do this is to gift someone the "1 Minute Ultrasound" app...it's the right price for medical students.
        05.21.12
        by

        I See Right Through You – Intro to EM Ultrasound

        The Gist:  Within the Emergency Medicine (EM) realm, ultrasound (US) is gaining an incredible amount of momentum.  Once relegated solely to use in FAST (focused assessment with sonography for trauma) exams, obstetrics, and placement of vascular catheters, US use and its application are growing in EM.  Keep up by using US often, getting this application, and learning from these guys.

        Radiology is boring so why should I care about US?  It takes too much time.  They're just going to get a CT anyways.
        • Surprisingly, I occasionally let my "inner nerd" shine.  My discovery of EM US has highlighted this personality attribute, typically when discussing a patient's workup and my suggestion for an ultrasound is met with a scoff or a blank look.  I launch into a giddy medical student frenzy citing recent papers on the risks of radiation and efficiency of bedside US.  This is exciting stuff!  
          • Both the medical and lay communities are exploring the burgeoning use of CT scans and the costs and risks associated therein, particularly in younger patients.  Thus, as a no-radiation study, US is gaining ground as a first-line imaging modality.  As a public health student, it's easy to get excited about the ways in which bedside US can help achieve better patient outcomes.
        • Immediate gratification.  Medical students seemingly live for the pursuit of test results.  With US, one gets immediate feedback, readily allowing appropriate treatment and disposition.
        • Bedside US can be quick.  Many challenge this point, but data are accumulating to suggest that ED length of stay (LOS) can actually decrease with bedside ultrasound by EM physicians. 
          • Over a decade ago, a retrospective chart review demonstrated that patients with RUQ pain receiving a gallbladder US by EM residents had a significantly reduced LOS compared with those who had scans in radiology (1).
          • Recently, a twitter update alerted me to a study at Sinai where ED US in appendicitis was associated with a decreased LOS  (2). 
          • US for deep vein thrombosis by EM physicians also apparently decreases LOS (3)
        • The CT scanner is often clogged, probably because between 1/8 and 1/14 patients presenting to the ED in the United States receives a CT scan (4).
        But, US is so "operator dependent" and too "technical" for mere students.
        • These excuses began this blog in the inaugural post, "Ultrasound for Dummies," a tidbit one might never know due to the tortuous and tangential nature of this blog.  In reality, increased emphasis on excellent US training in the EM curriculum is proving the opposite of these common refrains - EM physicians can perform adequate and timely US.  EBMedicine has an excellent summary of the evidence behind ED US.
        • The key lies in hands-on practice...even more reason to get hooked early.
        • If the US is equivocal, you may still send the patient to the CT scanner (or perform other imaging/tests).  
        Perhaps I'm now slightly intrigued by US...where do I start?
        • The absolute first place to start is with the brainchild of Dr. Mike Mallin and Dr. Matt Dawson, Ultrasound Podcast where they "Make Horrible Doctors Decent and Good Doctors Great." (I wonder what they do to medical students?)
          • This podcast is entertaining, thorough, and emphasizes the practical application of US in the ED.  Warning: (1) A few portions of the cardiac US lectures are dense and technical - bear through this and keep the podcasts on your phone for future reference (2) Don't listen to this podcast whilst running or driving (the video is key and this could be dangerous) (3) Listening to these podcasts on the elliptical in a public space may be detrimental to your image, as they are prone to make one burst into a fit of laughter.
          • Although openly biased, the podcasts provide literature sources for the techniques presented and highlight aspects for future research.
          • The free 1 Minute Ultrasound application for iPhone and Droid makes US accessible and quick in the ED.
        • UC-Irvine has good, instructive video lectures downloadable via iTunes
        • Many EM programs offer US electives for visiting medical students.  I can't comment on the quality of these yet, but I will in the next few months.
        • Society of Academic Emergency Medicine (SAEM) has narrated lectures on a few techniques
        Looking for a manual-style breakdown of various ultrasound procedures?
        But, nobody around here ultrasounds...anything!
        • Ultrasound each other.  The EM interest group at my medical school set up some time in the Vascular Sonography program's lab.  Students and instructors from that program were available to introduce us to the world of US.  
          • Apparently, extra-firm tofu also works well for a delicious and inexpensive ultrasound simulation (reference #SAEM12).
        • Ultrasound is an intellectual epidemic in EM.  However, if you just can't wait until your time in the ED, one can manage to find utility for ultrasound in nearly any medical field.
          • For example, on a nephrology rotation, I somehow managed to introduce people to bedside IVC ultrasound and they got excited about doing it.  
        • EDs have variable access to bedside US.  Tactfully advocate for improved patient care and outcomes by demonstrating the amazingness of US through the "1 Minute Ultrasound" application or by pandering to an outcome they're passionate about (ex: ED LOS).
        Your charm and subtle enthusiasm for ultrasound piqued my interest in US...I want more! (Alternatively:  Supplement to an EM US elective)
        • Add the SinaiEM.us blog to GoogleReader
        • Case-based learner? Check out a plethora of neat case based videos.
        • Ultrasoundvillage.com has an amazing image library, sort-able by organ system
        • Search the web for EM US fellowship programs.  Many of these programs have extensive links and resources available, similar to the University of Arizona's list that provide excellent education.
        • There are also excellent blog posts at takeokun.com
        • The Stanford 25 take on bedside ultrasound, with various monotonic modules from USC. 
        • Initiate dialogue with other specialists, students, and attendings on the utility and meaning of EM US.  An easy way to do this is to gift someone the "1 Minute Ultrasound" app...it's the right price for medical students.
            05.21.12
            by

            I See Right Through You – Intro to EM Ultrasound

            The Gist:  Within the Emergency Medicine (EM) realm, ultrasound (US) is gaining an incredible amount of momentum.  Once relegated solely to use in FAST (focused assessment with sonography for trauma) exams, obstetrics, and placement of vascular catheters, US use and its application are growing in EM.  Keep up by using US often, getting this application, and learning from these guys.

            Radiology is boring so why should I care about US?  It takes too much time.  They're just going to get a CT anyways.
            • Surprisingly, I occasionally let my "inner nerd" shine.  My discovery of EM US has highlighted this personality attribute, typically when discussing a patient's workup and my suggestion for an ultrasound is met with a scoff or a blank look.  I launch into a giddy medical student frenzy citing recent papers on the risks of radiation and efficiency of bedside US.  This is exciting stuff!  
              • Both the medical and lay communities are exploring the burgeoning use of CT scans and the costs and risks associated therein, particularly in younger patients.  Thus, as a no-radiation study, US is gaining ground as a first-line imaging modality.  As a public health student, it's easy to get excited about the ways in which bedside US can help achieve better patient outcomes.
            • Immediate gratification.  Medical students seemingly live for the pursuit of test results.  With US, one gets immediate feedback, readily allowing appropriate treatment and disposition.
            • Bedside US can be quick.  Many challenge this point, but data are accumulating to suggest that ED length of stay (LOS) can actually decrease with bedside ultrasound by EM physicians. 
              • Over a decade ago, a retrospective chart review demonstrated that patients with RUQ pain receiving a gallbladder US by EM residents had a significantly reduced LOS compared with those who had scans in radiology (1).
              • Recently, a twitter update alerted me to a study at Sinai where ED US in appendicitis was associated with a decreased LOS  (2). 
              • US for deep vein thrombosis by EM physicians also apparently decreases LOS (3)
            • The CT scanner is often clogged, probably because between 1/8 and 1/14 patients presenting to the ED in the United States receives a CT scan (4).
            But, US is so "operator dependent" and too "technical" for mere students.
            • These excuses began this blog in the inaugural post, "Ultrasound for Dummies," a tidbit one might never know due to the tortuous and tangential nature of this blog.  In reality, increased emphasis on excellent US training in the EM curriculum is proving the opposite of these common refrains - EM physicians can perform adequate and timely US.  EBMedicine has an excellent summary of the evidence behind ED US.
            • The key lies in hands-on practice...even more reason to get hooked early.
            • If the US is equivocal, you may still send the patient to the CT scanner (or perform other imaging/tests).  
            Perhaps I'm now slightly intrigued by US...where do I start?
            • The absolute first place to start is with the brainchild of Dr. Mike Mallin and Dr. Matt Dawson, Ultrasound Podcast where they "Make Horrible Doctors Decent and Good Doctors Great." (I wonder what they do to medical students?)
              • This podcast is entertaining, thorough, and emphasizes the practical application of US in the ED.  Warning: (1) A few portions of the cardiac US lectures are dense and technical - bear through this and keep the podcasts on your phone for future reference (2) Don't listen to this podcast whilst running or driving (the video is key and this could be dangerous) (3) Listening to these podcasts on the elliptical in a public space may be detrimental to your image, as they are prone to make one burst into a fit of laughter.
              • Although openly biased, the podcasts provide literature sources for the techniques presented and highlight aspects for future research.
              • The free 1 Minute Ultrasound application for iPhone and Droid makes US accessible and quick in the ED.
            • UC-Irvine has good, instructive video lectures downloadable via iTunes
            • Many EM programs offer US electives for visiting medical students.  I can't comment on the quality of these yet, but I will in the next few months.
            • Society of Academic Emergency Medicine (SAEM) has narrated lectures on a few techniques
            Looking for a manual-style breakdown of various ultrasound procedures?
            But, nobody around here ultrasounds...anything!
            • Ultrasound each other.  The EM interest group at my medical school set up some time in the Vascular Sonography program's lab.  Students and instructors from that program were available to introduce us to the world of US.  
              • Apparently, extra-firm tofu also works well for a delicious and inexpensive ultrasound simulation (reference #SAEM12).
            • Ultrasound is an intellectual epidemic in EM.  However, if you just can't wait until your time in the ED, one can manage to find utility for ultrasound in nearly any medical field.
              • For example, on a nephrology rotation, I somehow managed to introduce people to bedside IVC ultrasound and they got excited about doing it.  
            • EDs have variable access to bedside US.  Tactfully advocate for improved patient care and outcomes by demonstrating the amazingness of US through the "1 Minute Ultrasound" application or by pandering to an outcome they're passionate about (ex: ED LOS).
            Your charm and subtle enthusiasm for ultrasound piqued my interest in US...I want more! (Alternatively:  Supplement to an EM US elective)
            • Add the SinaiEM.us blog to GoogleReader
            • Case-based learner? Check out a plethora of neat case based videos.
            • Ultrasoundvillage.com has an amazing image library, sort-able by organ system
            • Search the web for EM US fellowship programs.  Many of these programs have extensive links and resources available, similar to the University of Arizona's list that provide excellent education.
            • There are also excellent blog posts at takeokun.com
            • The Stanford 25 take on bedside ultrasound, with various monotonic modules from USC. 
            • Initiate dialogue with other specialists, students, and attendings on the utility and meaning of EM US.  An easy way to do this is to gift someone the "1 Minute Ultrasound" app...it's the right price for medical students.
                05.17.12
                by

                Fellow Students, Lend Me Your Ears – EM Oriented Podcasts

                The Gist:  Podcasts are a way to absorb information in an efficient, pragmatic manner and the Emergency Medicine world does them well.  While many medical schools record lectures and place them online, podcasts enable one to listen to lectures that are meaningful and relevant on an individual basis.  Choose your own lecturer, style, and classroom for a world-class education.  The quality and quantity of podcasts is continously growing, thus this entry will change accordingly (fellow students, share your opinions).

                Again, aren't these things nerdy?  
                • The following features really make them worthwhile:  (1) Rewind (30 seconds) - Amazing for those of us with compromised attention spans. (2) The 2x speed option - studying in half the time, leaving time for fun!  Know as much as the gunners without acting like one.
                • MedEd Beach Body Workout!  I started listening to podcasts so I wouldn't feel guilty about carving out so much time from school/studying to enjoy solid daily workouts at the gym.  Now, my playlist has lengthened and my body's in better shape...that's literally active learning.  
                • The world becomes your class room.  Feel guilty about going to the beach when everyone else is at the library cramming for the USMLE?  Not anymore..these podcasts are actually great prep and they travel well.
                • On a more serious note, Life in the Fast Lane (LITFL)  gives a great rundown here of the benefits, drawbacks, and utility of podcasts.  
                • Note:  Despite the extent to which I pared down the list, it may seem overwhelming so start with one or two.  
                What are these "podcasts?"
                • LITFL has a comprehensive and searchable database.  
                • As usual, LITFL is comprehensive.  This posting merely exists to demonstrate one student's take on the podcasting world in hopes of making the navigation of this virtual world easier for other students.  Within each subcategory below I've listed the podcasts in the relative order in which I recommend them.  I was introduced to podcasts via EMCrit and just recently began listening to EM Basic.  Logic dictates the reverse...Learn from my mistakes.
                • These podcasts will equip you with incredible knowledge and keep you current to provide the optimum patient care.  Just know that your knowledge may make you appear ridiculous at times.  For example, during my first month of third year clerkships, I spent a weekend exploring life in the ED.  While working up patients, I included some things I learned from the EMCrit podcasts: (1) delayed sequence intubation in an agitated and deteriorating COPD patient and (2) the HiNTs battery in working up a posterior stroke.  On both occasions I was met with laughter and stares, which is rather embarrassing, regardless of the frequency with which it occurs. 
                  General Medicine for the Early Med School Years: Having trouble understanding the importance of the citric acid cycle or intracellular ion shifts during basic science lectures?  Fell asleep during class?  Augment this dry knowledge with relevant clinical scenarios and understanding.
                  • Anatomy for Emergency Medicine delivered succinctly and in sweet dulcet tones courtesy of Dr. Andy Neill.  These are superb, brief videos that really emphasize the clinical aspects of anatomy.
                  • University of Iowa Department of Emergency Medicine - A great archive of lectures covering common ED presentations as well as some procedural videos, which I wouldn't entirely write off.  UW EM Educational podcast is similar and also excellent.
                  • ICU Rounds - Dr. Jeffrey Guy.  New episodes are unpredictably published on iTunes but the old episodes are a wealth of information and often very good about reviewing the physiological underpinnings.  These are a great clinical supplement to physiology/biochemistry! 
                  • Surgery 101 - This is a regular, ongoing series targeted specifically to medical students on clinical clerkships.  It's a great supplement for anatomy and EM, with episodes on trauma, abdominal pain, appendicitis, etc.
                  • Hospital Medicine with Dr. Gil Porat - great for any student on clinical clerkship, even those unswayed by EM's amazing nature, yet.
                  The Best of the Emergency-Medicine-Centric Podcasts for Students:  
                  • Want to know the basic approach to common EM scenarios?  Check out EMBasic - Dr. Steve Carroll.  This is a great podcast to begin with as the podcasts are succinct, clear reviews of major topics in EM twice each month.  Recently, Dr. Carroll has added a new component with a Monday morning review of a practice changing piece of literature.  This is such a jewel and an incredible primer for all medical students on clinically clerkships.
                  • ERCAST - Dr. Rob Orman.  Each podcast tackles a different topic, often with a guest "expert" in the field.  You'll learn a ton of pragmatic information, including ways to reduce shoulders (Cunningham technique) and amazing ways you and your friends can ruin dinner conversation for nearby diners (reference disimpaction episode). 
                  • Duke Emergency Medicine - Here you'll find recordings of a smattering of Duke's EM Residency didactics.  The audio quality varies on these but there is a cornucopia of well-delivered knowledge (great talks on radiation, imaging, and toxicology).  Additionally, these really emphasize the fundamental scientific foundations - I wish I had these as a second year student.
                  • Ultrasound Podcast - These are excellent video podcasts (vodcasts) that represent the pinnacle of medical education - funny, concise, informative, and engaging.  These guys, Dr. Mike Mallin and Dr. Matt Dawson, can make anyone passionate about this imaging modality.  They also have an incredible iPhone/Droid app "1 Minute Ultrasound."   
                  • Free Emergency Medicine Talks - These are great talks also available on iTunes and cover important EM topics such as the utility of positive pressure ventilation, rapid sequence intubation in head injury, and the use of standard labs for undifferentiated abdominal pain.  Talks downloaded from the site (ex: from major EM conferences) can be converted into podcasts for quicker listening.  Right click on the selection, choose 'get info,' then 'options.'  Then change media type from 'music' to 'podcast.' 
                  • The EM Res Podcast - Dr. Bob Stuntz's podcast is new to the scene but has thus far proved to be an excellent addition with reviews of basic topics in EM.  I have a feeling there's much more goodness to come!
                  • Emergency Medicine Cases - These episodes delve more deeply into the workup and treatment of various common ED ailments.  
                  • EMPEM - great pediatric supplement address common pediatric complaints with literature and evidence reviews.  Great episodes on bronchiolitis and the like but nothing out in quite some time!
                  • PEMED - newer podcast related to all things pediatric.  This is a necessary supplement so one doesn't end up treating children as merely small adults, including procedural tips for LPs, airways, and IVC imaging.  
                  • Practical Evidence - Dr. Scott Weingart's podcast succinctly summarizing one ACEP clinical policy (ex: penetrating neck trauma) each episode.
                  • Feeling rugged?  Even if the answer is no, check out Dr. Minh Le Cong's podcast Prehospital & Retrieval Medicine (PHARM).  The PHARM provides excellent conversations on basics of EM, retrieval medicine, and debates on current controversies within EM.   There are excellent episodes that aid in understanding the airway and other crucial components of EM in better detail and with finer finesse.   This is a new podcast but truly a gem and accompanied by a great blog, as well. 
                  • ToxTalk from the University of Massachusetts.  This podcast is somewhat sporadically put out but is packed with toxicology gems.  
                  Want to look (and be) well read?
                  • Annals of Emergency Medicine - Monthly highlights from the journal with discussion of important and controversial articles.
                  • Persiflager's Infectious Disease Puscast - Yes, this revoltingly named podcast is actually a gem.  The Puscast is a twice monthly summary of the latest infectious disease literature, hosted by the humorous Dr. Mark Crislip.
                  • Keeping Up! from Vanderbilt has some great old episodes that review various papers in the EM literature and distill the papers into basic points.  Delve into the old episodes for some great information. Newer episodes are short snippets reviewing current articles in EM literature, distilling each piece into the good, bad, and take-home points.  A mobile app is on the horizon from this group!
                  Insatiable appetite for the front lines of EM?  These are a must!
                  • EMCrit - Dr. Scott Weingart.  Cutting edge topics in EM and critical care.  These podcasts are amazing and innovative but are oftentimes at the forefront of critical care and EM and may occasionally be beyond the medical student scope.  There are plenty of practical jewels for medical students though, including airway pearls, understanding ETCO2, lactate, and great discussions with Dr. Rivers on the "Surviving Sepsis" campaign, etc.
                  • SMARTEM - Dr. David Newman and Dr. Ashley Shreves dive extremely deep into the evidence on various topics that will wreck your understanding of common topics such as treatment of acute pharyngitis, chest pain risk, CT scanning, and stress testing.  These are dense; however, there are excellent supplements from the blog Sinai EM Media Site.
                  Miscellaneous goodness if you have the time:
                  • A Gobbet o' Pus - Sounds nasty but these short 5 minute cases by Mark Crislip are ID pearls and are generally entertaining, interesting, and quick.
                  • EM: RSI - There are only five episodes on this "Residency Survival Information" but they are excellent.
                  • There are a good number of "Grand Rounds" podcasts from Boston University, UW EM, Sarasota Memorial, etc.  Explore these as these podcasts are excellent and generally address a single topic in depth by an expert in that field.
                  • Learning Radiology - it's crucial to be able to interpret your own films and images, this is a great Q&A style video cast 
                  • I should probably listen to these but haven't yet.  It's EMRACast and they're podcasts on preparing for the residency/match trail.  Also ACOEP has some new student podcasts on their site but they're not in iTunes thus far. 
                  • EMRAP has some free podcasts and some interesting ones on medical education
                  • A shout out to the pre-doctoral fellows at my medical school for their DidacticsOnline podcast.
                  But I'm a visual learner and I still haven't had enough! 
                  This is a different beast...Check out Vimeo.com where you can subscribe to LITFL's feed.  There's also
                  Mind-blowing Goodness at HQMedEd.com and from Academic Emergency Medicine