Indulging in Intubation – Lessons for the Novice

The Gist:  Learning endotracheal intubation (ETI) is both a privilege and a risky endeavor.  As patient safety is of the utmost importance, some situations may not be appropriate for novice intubators.  Dr. Minh Le Cong posed a question regarding who should intubate, discussed here, and Dr. David Marcus also has posts on this topic here and here. There are some things, however, that a novice intubator can do to maximize their learning process in an efficient and safe manner.
  • Note:  I'm not an expert and this is not an evidence-based review.  This is essentially a "Tricks of the Trade" post.
Last year, I wrote this post after an anesthesia rotation.  I'm finishing up a final airway elective, both in preparation for residency and as a gift to myself after a month of public health research. I realized I had benefited from many things gleaned from Free Open Access Medical education (FOAM) world.  Here are some things that have made an impressive difference..

My Top 10 List
1.  Know what you're getting into.   Dr. Minh Le Cong has built a #FOAMed airway curriculum.
2.  Do an anesthesia rotation.
  • Allows for controlled, planned control of the airway.  This is part of the PGY-1 curriculum in U.S. EM programs, but it's also helpful as a medical student where one can easily get 40-50+ intubations in a month.  
  • Allows one to see what happens after the tube is secured such as response to pain, duration of medications, ventilator management.  
  • On a non-airway note: excellent for nerve blocks and arterial lines as well.
3.  Verbalize what you see see and do every step of the way during ETI.
  • An attending once told me, "It feels like an eternity when you're not holding the laryngoscope." Attendings get nervous if they can't see what's going on.  Let everyone know when you're "in the vallecula" if you're using a Macintosh blade, when you see cords/arytenoids, or if something (like cricoid) isn't working. 
4.  Know the physiologic responses to induction drugs and laryngoscopy.  Control of an airway isn't just about placing the tube - induction drugs, laryngoscopy, and the patient's underlying medical status do bizarre things to hemodynamics.  When it becomes available, check out the lecture given on the opening day of the Social Media and Critical Care Conference by Dr. Scott Weingart.
  • Post-intubation hypotension (PIH)
    • Heffner et al: 1 year retrospective cohort (~1/2 eligible were excluded) showed that PIH is common (22%, n=66) and associated with respiratory processes and a shock index (HR/SBP) >0.8 prior to ETI.  The percentage is essentially the same as their prior study (23% with PIH; nearly all intubated with etomidate, often referred to as "hemodynamically stable").
    • Another, more heterogeneous study by Green et al, didn't show any clear associations between PIH and medications but demonstrated that patients with underlying respiratory issues are more likely to have PIH and sustained PIH is associated with badness on the mortality front.
  • In the OR, the induction propofol and fentanyl were always backed by sticks of phenylephrine "just in case."  A recent EMRAP episode (subscription required) featured a debate on this concept between Drs. Amal Mattu and Scott Weingart.
  • Laryngoscopy causes stimulation of the sympathetic and parasympathetic innervation to the hypopharynx, larynx, and trachea.
    • Increased heart rate (~30 bpm) and blood pressure (~25mmHg) thought to be due to release of catecholamines secondary to CN IX,X stimulation and renin-angiotensin aldosterone system (1).  
    • Bronchoconstriction due to parasympathetic stimulation (1).
    • Note: Pediatric patients may have bradycardia, pretreatment with atropine in some infants is of controversial utility (1).
5.  Use airway adjuncts.
  • Video laryngoscopy (VL) devices often require a different skill set in passing the tube through the cords. Some institutions have one start with VL before direct laryngoscopy (DL) but in others, this is not routine practice, so get some experience.
  • Mask ventilation.  Practice the two-handed technique, not the inferior E-C taught in BLS (Hart et al).
  • Get a feel for the bougie - it can be surprisingly difficult to induce memory.
6.  Use a combined VL/DL device if you have one available.  
  • Allows attending to visualize structures to augment safety and correct the learner. 
7.  Know your limits. First-pass success in ETI is important, keep this and the patient in mind.  Opportunities may arise when a difficult airway is placed in your hands.  Know when to say no or ask for help.
  • A recent retrospective analysis of ED intubations in Academic Emergency Medicine by Sakles et al demonstrated adverse events (AE) increase with a greater number of ETI attempts.
    • 1st pass success = 14.2% with AE (n=1333; 72.9%)
    • Multiple ETI attempts = 53.1% with AE
    • Note: AEs included esophageal intubation, oxygen desaturation >10% (most common), hypotension, dysrhythmia, laryngospasm, etc.  Some of these are probably more clinically important than others.
  • A multi-center prospective study of n=2616 in Japan by Hasegawa et al demonstrated an adjusted odds ratio of 4.5 (95% CI 3.4 to 6.1) for AE in multiple attempt ETIs.
      8.  Establish an airway plan.  Seemingly easy, straight-forward airways can become surprisingly difficult.  As an attending told me, "the purpose of procedures in Emergency Medicine is to keep you humble."  Stay curious and never assume you've "got it in the bag." The scariest ETIs I've been a part of were unanticipatedly difficult, perhaps, in part, due to lack of preparation.
      • Talk through your plan with the attending/team to ensure you have an appropriate plan, communicate the plan, identify any pitfalls, ensure proper materials, and demonstrate knowledge. 
      • In the ED, even if you plan to do DL, bring the VL device to the bedside.  If DL fails, the back up plan is ready. 
      • Identify and plan for patient co-morbidities such as pulmonary disease, obesity (see video by Dr. Winters, EDexam post, GI bleed, increased intracranial pressure, or trauma.  
      9.  Remember that ETI doesn't end with the passing of the tube.  
      • Ensure your patients have sufficient analgesia on board.
      • Ensure ventilator settings are appropriate to the situation.  For example, some patient populations need longer expiratory times (asthmatics) or higher respiratory rates (DKA, salicylate ingestion, need for CO2 regulation).
      • This EMCrit post has some neat checklists at the bottom to help one systematize post-intubation care.
      10. Avoid hypoxia.
      • Use apneic oxygenation (NODESAT).  If the attendings don't use this, it offers an opportunity for discussion (at an appropriate time, away from the patient's bedside).  
      • Recognize pulse oximeter lag and the limitations of the pulse oximeter, as demonstrated by Dr. Rob Bryant.  
      Note:  some attendings may interpret some of these points as a "sign of weakness," so be prepared and do what's best for the patient.

      References:
      1.  Ron Walls and Michael Murphy.  Emergency Airway Management. 3rd edition. 2008: Philadelphia, p222-229.

        What’s the MATTER(s) with Tranexamic Acid?

        The Gist:  The anti-fibrinolytic, tranexamic acid (TXA), may be lifesaving in the context of hemorrhagic trauma with fewer thrombotic complications than other agents; however, perfect data is lacking.  Use and availability of TXA is varying within the U.S. - it just hasn't caught on in many places.  Is this due to weakness in the data? Lack of pharmaceutical promotion? Lack of education?  Should we wait for more studies?  I only have guesses for answers..  Follow the evolving literature on this topic and check out the MATTERs study by Morrison et al (full text).  Although it's not an RCT, it offers additional, if imperfect, data upon which to inform our knowledge and discussions on TXA, especially regarding patients may benefit the most.

        Many centers in the United States don't have TXA or don't incorporate it in their massive transfusion protocol.  Some of this may be the result of skepticism regarding the small absolute mortality benefit in CRASH-2, lack of additional prospective studies, appropriate indications,doses, time frame, and side effect profile.  Yet, many physicians don't know about the drug as the inexpensive drug lacks a marketing campaign from the pharmaceutical industry.  This is where free, open access, medical education (FOAM) may have a role in the knowledge translation gap regarding TXA.

        In the FOAM world, chatter abounds about the CRASH-2 study and subsequent sub-group analyses (see PulmCCM, St. Emlyn's, Trauma Professional, Resus.Me).  In fact, some even suggest pre-hospital TXA to maximize the apparent benefit of early administration.  Also, a 2012 Cochrane Review (CRASH-2 authors) recommends TXA within 3 hours of injury in the bleeding trauma patient.  Aside from a reference on this EMCrit podcast, other studies on TXA seemed non-existent and drew from the massive cohort in CRASH-2.  In fact, I wrote a post on some of the barriers to TXA knowledge translation last year and initially neglected the MATTERs trial.

        Why does this study matter?
        • Study population:  Actively bleeding patients versus those suspected of actively bleeding in CRASH-2.
          • CRASH-2 had more subjective inclusion criteria, part of which had the uncertainty principle at play.
        • Confirmed results of CRASH-2, showing a mortality benefit with TXA
          • 1.5% ARR in CRASH-2 vs 6.5% ARR in MATTERs
        • Demonstrated that the most severely injured cohort might benefit the most
        Methods
        • Retrospective cohort, single center (military hospital in Afghanistan). 
        • Included: n = 896 patients who received at least 1 unit of PRBCs within 24 hours of admission after combat injury
          • Hospital protocol:  all trauma patients receiving emergency transfusion with evidence of hyperfibrinolysis (rotational thrombelastography) also received a 1g bolus of TXA and additional TXA at the discretion of the physician.
        • n=293 received a mean of 2.3 g TXA within 1 hour of injury (125/293 also had massive transfusion)
        • n=603 didn't get TXA (195/603 had massive transfusion)
        Results
        Overall
        Massive Transfusion
        • Absolute in-hospital mortality reduction in TXA group - 6.5%
        • Absolute reduction in the TXA + massive transfusion (10+ units of blood products in 24 hours) group was 13.7%
        • Sickest patients received TXA (and did better)
        • More VTE in TXA cohort (n=15 in TXA cohort vs n=3), but too few to assess for
          • Pulmonary embolism - 2.7% (TXA) v 0.3%
          • Deep venous thrombosis: 2.4% (TXA) v 0.2% 
        • No reduction in blood products in TXA cohort
          • Note: This may be due to a survivorship phenomenon.
        Limitations
        • This study was conducted at a single military hospital so generalizability may be limited.
        • No randomization
        • Retrospective cohort
        • Really quick time to administration of TXA
        • Thrombelastography is not regularly used in most EDs in the US
        Things to keep your eye on in the future:
        • CRASH-3 Trial -international, multicenter, pragmatic, double-blind RCT to quantify the effects of the early administration (<8 h of injury) of TXA on death and disability in patients with a traumatic brain injury. (end of follow up in 2017)
        Reference:

        The Modern Matthew Effect

        The Gist:  In medicine and science, regardless of the medium - traditional or Free Open Access Medical education (FOAM)- the Matthew effect exists, potentially perpetuating knowledge and dogma that doesn't necessarily reflect intrinsic worth.  Question the medical dogma, respectfully and, while it's easy to copy and paste a citation for a quote a popular figure, consider critically evaluating the source of information or primary literature.  In words borrowed from TheSGEM podcast, "Be skeptical of everything you learn.." (to a healthy, not pathologic degree) - it's another arrow in the metacognition quiver.

        Conversations on the perils of FOAM at the Social Media and Critical Care Conference (SMACC) spurned the following, something I think is worth reminding ourselves of from time to time:
        While many of us exercise healthy skepticism we can still fall victim to a common phenomenon because, in the words of Daniel Kahneman in Thinking Fast and Slow, we have "almost unlimited ability to ignore our ignorance."  We may think we are fully aware of our biases, but they are worked into the fabric of life.  

        The Matthew Effect (with regard to references):  essentially, the greater number of times a paper is cited, the more citations it will receive.   Coined by Merton in this paper, but initially researched by Harriet Zuckerman, it is borrowed from the Gospel according to St. Matthew: “For to all those who have, more will be given, and they will have an abundance; but from those who have nothing, even what they have will be taken away” (Matthew 25:29) (1).  
        • The Matthew effect is partially a byproduct of quality.  A content expert likely becomes trusted and their work becomes highly regarded due to the merit of their prior work(s).  Thus, this is a sort of natural phenomenon in any field that has experts/masters in particular disciplines.  Zuckerman identified this in that Nobel Prize winners tended to generate/produce more awards compared with those who had shared equally in the project but were more junior researchers (1).
        How does this manifest in medical literature?
        High Impact Journals.  Impact factor (IF) - The IF is essentially the average number of times an article in the journal is cited within the previous two years.  journal’s prestige is a function of the quality of the articles appearing in it. 
        • What happens when the exact same article (title, author, etc) is published in two journals with disparate IFs?  This paper by Lariviere and Gingras (full text) took at look at this question and found that duplicate papers (4532 pairs of papers) in high impact journals obtain, on average, twice as many citations as their identical counterparts published in journals with lower IFs.  
        • The intrinsic value of a paper is not the only reason for the citation of a specific paper; there is a Matthew effect attached to journals.  Thus, a paper published in a high impact journal has an added value over its intrinsic quality and will generate more citations.
        High Impact Authors.  A high profile author's paper is likely to carry more weight or gain more recognition.
        • Example:  In the Feb. 2013 edition of Emergency Medical Abstracts (subscription required), there's a little bit of banter about how this paper on incidence of contrast induced nephropathy was referred to ("the Kline paper").  Pulmonary embolism guru Dr. Jeff Kline is listed on the paper but the first author is actually Dr. AM Mitchell.  
        This sounds like splitting hairs..  Perhaps a little, but not necessarily.
        • Implicit in the concept of the Matthew effect is the notion is that a piece of research is more valuable or important because of its association with an individual rather than the contents, quality, or implications of the research.
        • Without realizing it, we may become susceptible to a cognitive bias secondary to the "Halo Effect," which I first heard about in Thinking Fast and Slow by Daniel Kahneman.  For example, if an individual is widely regarded in the community for a podcast or publication, their institution may be looked upon more favorably.  
          • Dr. Weingart's tweet at the beginning of this post demonstrates potential implications of the halo effect - a positive/powerful reputation may have undue influence over whether we see that information as important or valid.  If someone we respect says an article is a "must read" or "garbage" we have formed an impression of the article prior to actually reading it.  They may very well be spot on, but this is something to keep in mind.
          • In an era of information overload, especially in medicine, we may deal with this cognitive load by perceiving a reputable person's recommendations as most/more important (known as positional cues).  This may skew our evidence base or perception of prevalence or importance of a medical problem.
        Is FOAM impervious to this effect? No.
        • FOAM has a form of Impact Factor.  This can be quantified in retweets, blog hits, or a spot  in a Life in the Fast Lane Weekly Review.  Again, this is not necessarily a negative thing and can be harnessed "for good," introducing innovative or important ideas quickly and diffusely across the globe.  
        • Example:  
         
        • The social connections and the platforms associated with FOAM are intricate (hospital and professional networks, friends/families (social media), affiliations with societies, etc).  As a result, the Matthew effect may be less like the "Nobel Prize" effect noted by Zuckerman as age, rank, and location may not carry as much weight and the sources are vast.
        • Recently, Google announced that it would drop its RSS aggregating service, GoogleReader. This move immediately induced a Twitter frenzy regarding replacement services.  One focus of conversation on this topic from some members of the FOAM community was that Twitter has replaced the need for RSS.  This article discusses this notion, a debatable assertion that I don't personally find applicable to my use of RSS.  Should Twitter supplant RSS, individuals who use an RSS aggregator to review journals and/or medical blogs may have increased susceptibility to biases associated with a social media/recommendation system based system. 
        So what do we do?
        • Question productively and respectfully.  
        • Check sources.  For example, while putting together this post on elevated blood pressure in the ED, I came across a statistic in Tintinalli:  3.8% of headaches in the ED have serious intracranial pathology (Ch. 159).  Initially, I copied this statistic and reference because Tintinalli is one of the core EM texts.  FOAM has inspired me to check things out further, and upon evaluating the study I found it underwhelming to support the rate quoted.  This study was referenced by others as well, including the famous Perry et al article on subarachnoid hemorrhage and others. 
        • Keep the Matthew effect in mind when evaluating articles, watching posts/ideas go "viral", or evaluating the validity of an assertion or claim.
        Updated 3/18/13.

        References:
        1.  Zukerman H.  Scientific Elite:  Nobel Laureates in the United States. 2d ed. (New York:  Transaction Publishers, 1996). 

        Drinking from the Firehose – One Sip of FOAM at a Time

        The Gist:  Reading/listening/seeing does not equal understanding.  FOAM naturally serves as a conduit for spaced repetition - be open to the wide array of material and filter smartly.  Take advantage of spaced learning, including that offered by Free Open Access Medical education (FOAM), to learn more effectively.

        "Medical school is like drinking from a firehose.." We hear this refrain from the beginning of med school but the truth is that this will extend beyond our formal medical training.  As a result, we find our ways to cram what we can in, often one subject at a time.
        • Disclaimer:  I'm no expert, just a professional learner.
        FOAM seems like it could help with this but the there's an enormous breadth of content and some view FOAM as disorganized or overwhelming.  I, like many, have joked that emergency medicine folks love FOAM because it appeals to our attention deficit.  In fact, it is somewhat similar to a shift in the emergency department- there's no way I can predict my Twitter, podcast, or blog feed upon opening.  Trainees, educators, and seasoned physicians have expressed the seeming disorganization as a concern regarding FOAM.  However, there is another way of framing this input.

        Spaced Repetition - Dr. Chris Nickson of Life in the Fast Lane describes this excellently in Learning by Spaced Repetition and The Magic of Spaced Repetition.  Initially, I merely gleaned over the iTeachEM post as I scrolled through my blog feed to reach the stuff that I thought was actually relevant to me - medicine.  I was wrong.  Learners like me often don't value thinking about how we learn, we just want to learn what we need to know (how do we know what we don't know?).  I have realized, however, that it's actually helpful to understand how I think and learn, regardless of how well I believe I've mastered learning. Simply:
        • Over time, we forget things
        • Reminders, especially well timed one, mitigate this forgetfulness
        • Flashcards can work in this fashion but much medical information doesn't lend itself well to this practice (which can be cumbersome in a field like EM that spans...everything).  
          • Tip: I uploaded flashcards via GoogleDocs to a $1.99 iPhone application that had a "smart learning" feature which was really helpful in the first 2 years of med school for exams (and I could then go back to as I prepped for the USMLE).  There are other similar applications such as 
        There's relevant evidence behind this, too:
        • Randomized controlled trial by Kerfoot et al demonstrating effectiveness of spaced repetition in a urology clerkship and another RCT in urology residency programs.  
        • Kerfoot et al have several publications on this intervention, including this one that demonstrated issues with regard to completion of the intervention by students
        FOAM naturally produces spaced repetition through a call-and-response-like system, indicating that people are critically thinking about topics (while others of us quickly begin the process of forgetting, ready for an opportune reminder at any time).  Check out this example:
        Twitter debate (February)
        ALiEM post on PE diagnostics in Pregnancy (March)

        What's the key? My thoughts:
        • Don't be afraid to go back and listen to old podcast episodes, listen or re-read bits of FOAM you've already experienced - you can build and reflect upon what you've learned.  
        • Remember that FOAM offers far more than cutting edge medicine - Be open to all topics, even the seemingly mundane ones.  
        • Have a method of filtering FOAM topically for when you want to explore something in depth.
        For example:  search FreeEmergencyTalksLife in the Fast LaneEMgoogle, or pose a question on Twitter...Your own syllabus!
          • This can help steer you to literature/texts to read (or supplement/update the ones you have read). 
        • Have a method of saving bits of FOAM.  You can't get through it all.  See a paper tweeted that you should read or an interesting PV card?  Star it in GoogleReader, clip it to Evernote, or save it in Pocket.  It'll be easily searchable when you need it.
        • Shuffle.  Haphazardly download from FreeEmergencyTalks or put your podcast player on shuffle.  This may overcome the desire to listen to the 'latest and greatest' and act as a refresher on things you thought were previously mastered.  This does not mean abandon focused study or curriculum, but more of an encouragement to add on this layer.
        • Relax. FOAM isn't a requirement or a race, it's about learning - a tool.  Given our attention spans, the vast amount of information we have to learn, and the nature of truly understanding/mastering something we will miss things.  Fortunately, we will be reminded of these deficits - by a patient, an attending, or by FOAM
        Translation into practice (My wake up call to spaced repetition..but these examples occur daily):
        Patient #1 -  A 29 year old male brought into the ED via ambulance for two witnessed seizures, now in his "typical" post-ictal state - not responding to most question but protecting his airway and maintaining posture.  Vital signs were all stable and blood glucose was 88 mg/dL.  His wife provided most of the history, including an apparent "history of seizures," previously on multiple medications.  The patient began having another apparent tonic-clonic seizure.  While 2 mg of lorazepam was being retrieved, the seizure activity abated.
        • This case occurred during my first month in emergency medicine and I felt slick subtly and calmly helping the off-service resident assess and navigate the situation.   
        • With the patient stabilized, we dug through the hospital and clinics' notes and discovered that the patient was, in fact, diagnosed with pseudoseizures.  I felt so..used and wrong. The seizure seemed so real! I made a note to read on these.
        I read plenty, but forgot to read on pseudoseizures, as exciting as they sounded, and as many seizing patients that I saw.  Weeks later, I heard Dr. Mattu and company discuss psychogenic non-epileptic seizures (PNES) on the EMCast June 2011 episode.   I had been coerced into "reading up" on something I had dismissed as unimportant or boring.  (Note: EMCast episodes older than 6 months are now, or should soon be free).

        The discussion briefly focused on prolactin and I was briefly brought back to my time in the social work field when one of my clients had a letter from her neurologist stating that should she have a particular "episode," the ED should draw a prolactin level within 30 minutes.  Curiosity led me to a quick FOAM search led me to a a discussion on the BroomeDocs blog on prolactin.  

        The next week, I saw a patient with PNES in the ED after getting fooled again (which will happen with PNES).  Good job, FOAM, I got the nudge and read.  I began noticing that there were cases of PNES everywhere.

        Two months or so passed and, EMRAP (subscription required) reminded me again, of PNES.  That week, I was approached with two cases of suspected PNES.

        Ailments are so much more common when we know to look for them and when they're on the forefront of one's mind.  In EM, everything in medicine is on the figurative table.  FOAM has certainly helped me identify gaps in my learning, maintain a broad differential, and refresh my memory. 

        Updated March 2014

        Metacognition For The Pragmatist

        The Gist: Metacognition and cognitive errors in medicine are not merely fluffy, esoteric ideas. There are concrete steps one can take to mitigate these. Check out the Ten Commandments To Reduce Cognitive Error and Ten Commandments To Reduce Diagnostic Error by Dr. Leo Leonidas.

        As a student, my interests lie in the "meat" (or tofu, as it were) of medicine. Yet, as the breadth (minute as it is) of my clinical experience grows, I've become increasingly interested and aware of cognitive errors, especially my own. Why? Well, I think it will make me a better future physician. Cognitive bias, previously discussed here, is common in medicine and emergency medicine (EM). Metacognition, discussed in this post, can mitigate cognitive error by evaluating one's thinking. Although this seems esoteric, especially to the trainee, there are some concrete ways to go work through this process.


        Commandments to reduce cognitive and diagnostic errors
        Adapted from Dr. Leo Leonidas (1,2)

        Thou shalt think of serious and treatable conditions and act on them without delay

        • This is the crux of EM.  We must be facile with some of the most intense minutes of every specialty - retrobulbar hematoma, subarachnoid hemorrhage, asthma, cardiac arrest, or...anything! 
        • Know the killers and, as I learned from this EMBasic episode, always place a few in the differential.  

        Thou shalt mentally rehearse common and serious conditions that you expect to see in your specialty.
        • Simulation plays an expanding role in medical education, especially in EM where physicians must be skilled in life and limb-saving procedures that are rarely used. Preparation is crucial to making logical decisions under pressure and time constraints. Check out this paper by Dr. Cliff Reid (full text).
        • There is a cornucopia of FOAM procedure videos and tips, available regardless of one's proximity to a fancy simulation center . Examples include: Life In The Fast Lane repository, Procedurettes, EMCrit's Thoracotomy Episode, and so many more out there (use EMgoogle).
        Thou shalt not rely on your memory when making critical decisions.
        • Check the actual vitals, labs, etc when making crucial decisions or talking with consultants. EDs are insanely busy and it's difficult to keep things straight, no matter how sharp the mind.  
          • I overheard a conversation in which a PCP received a call to admit a syncope patient and, when the PCP asked about the patient's blood pressure, the ED doctor stated it was "about 150's systolic." Upon review of the patient's chart, her systolic BP was 90mmHg throughout her ED stay. This misinformation didn't result in harm, but it certainly pointed to potential cause of syncope and a lack of attention to detail.
        Thou shalt consider other possibilities even though you are sure of your first diagnosis.  
        • Always think of a differential, even if it's a "slam dunk" case. This can help avoid anchoring bias as well as diagnostic momentum bias.
        • Continue the debate and questioning even though the data is “in,” this will help mitigate confirmation bias and premature closure (see ALiEM post). 
          Thou shalt maintain a high index of suspicion or uncommon presentations of the common.
          • Know the probability and epidemiology of the diseases in the your differential but, in order to lessen availability bias, also recognize that zebras exist.  Include one in each differential, it's a great thought exercise and the diagnosis doesn't have to be worked up fully solely because it's on the differential.   
          • Patient's often don't present in the "classic" or "textbook" way.  According to Dr. Amal Mattu, "Classic, in medicine, means 15% of the time."  Sounds about right.
          Thou shalt be wary of your hunches and intuitions; use Evidence Based Medicine (EBM).  
          • Gestalt plays a huge role in EM.  As discussed in this post, however, this is something that evolves over the course of an entire career and is something that trainees like myself are fiercely trying to cultivate. 
          • Clinical experience and anecdotes play a formative role in the development of a physician yet come at a price.  We are more likely to remember the 1 in 1,000,000 exception than the mundane 999,999.  These make great stories and provide learning points, but we probably shouldn't become reactionary to the outlier.    
          • EBM is not infallible and there are instances in which there is insufficient, applicable evidence to guide decision making.  However, in many cases there is a body of global experience with a particular disease or intervention.  It would be foolish to not capitalize on the best available information to provide the best patient care.
          Thou shalt take time to decide.
          • At the end of a night shift with a packed waiting room, it may be worth pausing for a moment to think about the 55 year old with abdominal pain. Reconstruct the story without segments spent dealing with the combative drunk, the code, and the literal pain in the neck. There are situations in which action is paramount; however, in most cases there's time to think. 
           Thou shalt engage in accountability procedures and follow up for decisions. 
          • Follow patients - it's a myth that emergency physicians can not or should not engage in follow up.
            • Keep a protected list of patients for each shift - using logs, stickers, or lists in the medical record software. 

            Thou shalt request a test only if it will change your plan or help in predicting the outcome.

            • Danger exists in too much information as it can lead one astray.  Think about how a test is relevant and will change management (ALiEM post). The pieces must fit, otherwise an extraneous bit of information could lead to search satisfying bias. 
            • Testing and treatment has associated risks, for a review, see the St. Emyln's posts on this topic.
            • Diagnosis is largely in the history and physical exam, make sure that the data fits with the story and the patient's clinical exam and vice versa.  As trainees, it's crucial to hone the history and physical skills, particularly for short ED encounters. 
            Thou shalt use available databases.

            • Use an iPad, tablet, or iPhone to readily access information. Consult applications, calculators, and pharmacopeias to double check medication dosages and adverse effects.
            • Colleagues often have niches - in ECGs, stroke, toxicology, etc. Pause to run cases by others for a fresh or alternative perspective.  
            • Lucky enough to have an ED pharmacist? Consult with them to reduce error (Patanwala et al, Cohen et al).
            • Electronic medical records systems allow one to view recent hospital visits and lab work, helpful in piecing together a coherent story.
            • Prescription monitoring databases can be a valuable resource. ACEP recommends using them (Level C).

            Thou shalt reflect on how you think and decide.
            • Recognize your own beliefs, biases, prejudices, and thinking style.  This is one of the toughest commandments, as it requires introspection and reflection.  For example, I know that I often have the tendency to mentally apply EBM and literature before fully assessing a patient's nuances.  Knowing this, however, I benefit from a mental pause checkpoint.  
            • Check out talks from FreeEmergencyTalks.net on this by Dr. Croskerry.
            • Heuristics, often cultivated by gestalt, are frequently used in medicine.  Check out these articles by Wegwarth et al and Marewski to see some ways in some ways in which heuristics can be created and tweaked to as a form of decision support.  

            References:

            1.Leonardo Leonidas.  "Ten Commandments to Reduce Diagnostic Errors."  Given to the Class of 2001 Tufts University School of Medicine From Dr. Leonardo Leonidas, Bangor, Maine, 20 May 2001  

            2.Leonardo Leonidas. "Ten Commandments to Reduce Cognitive Errors."  2003.

            You Want Me To Stick That Tube Where? – Utility of the Nasogastric Lavage

            The Gist:  Upper gastrointestinal bleeds (UGIB) can be serious and scary, so diagnosis and treatment are essential skills in the ED.  Nasogastric tubes (NGT) are uncomfortable and are not necessary in many UGIB or potential UGIB.  A negative nasogastric lavage (NGL) doesn't mean much, but a positive one is pretty specific.  It may not be worth fighting GI over, but think about the patient and utility of the procedure first and know that the American College of Gastroenterology 2012 Peptic ulcer UGIB guidelines say it's not required for diagnosis, prognosis, or treatment (is airway a problem? patient uncomfortable?). 

            The Cases:  
            1. 23 y/o female with history of bipolar disorder and recent URI presented after "seeing some blood in my vomit" (further history sounded less like hematemesis and more like a spitting up a small bit of blood after a bout of coughing).  She took 600 mg ibuprofen three times daily for headaches over the past 3 days but had no other symptomatology. Vitals WNL, PE: unremarkable, Hb 13.5 g/dL, chemistry WNL.  

            2. 63 y/o male with a history of atrial fibrillation and COPD presented with two episodes of hematemesis and more shortness of breath than his baseline. He was on warfarin, lisinopril, atorvastatin, carvedilol, furosemide, and a myriad of inhalers.  VS: BP 118/78, P 100, R 18, O2 94% RA.  PE: pale, no diaphoresis, abdomen soft, non-tender.  Hb 7.6 g/dL 

            The attendings asked the nurses to place an NG tube - in Patient #1 to rule out UGIB and in Patient #2, because it's part of their routine for UGIB.

            The outcome: Patient #1 - halted the NGT placement and left AMA.  Patient #2 - difficult passing NGT, NGT abandoned secondary to unsuccessful attempts, increased combativeness, and epistaxis.  His INR then returned at 5.6.  Patient was given vitamin K and admitted to GI for endoscopy.  

            NGT placement, cited as one of the most uncomfortable ED procedures, resulted in patient distress in these two cases.  (If you don't believe this, I urge you to have a medical student place one on you...I 'practiced' with a fellow student and began using topical anesthesia after that event).   Many people in the FOAM world likely don't routinely use NGL; however, I found that in keeping with EM practice variation, many emergency physicians do so I opted to explore the utility of this procedure.  

            The FOAM:
            Does NGL confirm UGIB?
            • If positive, yes.  Specificity 91% (95%CI 83-95%), +LR 11 (Witting et al)
              • It's not always clear "how positive" an aspirate is.
            • Negative aspirate cannot rule out an UGIB due to poor sensitivity 42% (95% CI 32-51%) (Witting et al). Recall that many UGIB occur in the duodenum, out of reach of the NGL.
            • Less invasive indicators in the history, physical, and lab work can point clinicians towards localizing the source.  See the Rational Clinical Exam from JAMA on this topic, demonstrating that melena, hematemesis, high BUN/Cr ratio, history of prior UGIB, and medication use are all good predictors.  So, if a patient clearly has hematemesis or melena, they really don't need an NGL to confirm UGIB.  
            • Counterpoint:  if a sick patient has rectal bleeding and signs/symptoms concerning for UGIB without clear stigmata (ex: hematemesis), NGL may point to a source easily and more quickly controllable with EGD.
            Any other use for NGL in UGIB?
            • Historically, NGL has been used to predicting the severity of the bleed and need for intervention by determining the rate of bleed.  For example, coffee ground aspirate often indicates a slow bleed whereas bright red aspirate may indicate a more brisk bleed.
            • Most cases of UGIB warrant an endoscopy and the question lies in when this procedure takes place - now or within the next day?
              • NGL may predict high risk lesions, but performance of an NGL doesn't change clinical outcomes (Huang et al
            • The need or anticipated need to claim the airway of a patient with UGIB may warrant an NGT (EMCrit:  airway in the GI bleeder).
            There are other ways to risk stratify UGIB..
            • The Glasgow-Blatchford Score (GBS) may have utility in risk stratifying patients prior to endoscopy.  The NICE guidelines allow for consideration of discharge for patients with a score of 0 but this isn't the standard yet in the US.   A simpler, modified GBS has also been developed and needs further validation for use in the ED to discharge patients.  Check out EM Lit of Note's perspective on this.  
            Does NGL affect patient oriented outcomes?  No, Huang et al showed NGL made no difference in:
            • Mortality (OR 0.84; 95% CI 0.37-1.92)
            • Length of hospital stay (7.3 vs 8.1 days, P = .57)
            • Surgery  (OR 1.51; 95% CI 0.42-5.43)
            • Transfusions (3.2 vs 3.0 units, P = .94)
            What about to clear the view for the endoscopy?
            • Erythromycin is just as good (ref)
              If an NGT must be placed... do so humanely
              • Topical anesthesia
              • Whit Fisher's  NGT "Hook" technique (haven't tried this myself)
                • Spray phenylephrine/vasoconstrictor in nose and then viscus lidocaine
                • Clamp nose and have patient lie back.
                • Place NGT tip in oropharyngeal airway and dunk that in ice water for ~ 1 minute. 
              The future...Small studies, but some interesting things being done:
              Final Note:  So, the FOAM world is moving away from NGL and the literature also supports this.  The following pieces in key journals call for a move away from routine NGL in UGIB. This is an example of the crux of medical interventions - Are we doing something just to do it or because it will give us meaningful information and change the patient's outcome?
              • Pallin DJ, Saltzman JR. Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc. 2011;74:981–984. PubMed
              • Pitera A, Sarko J.  Just say no:  gastric aspiration and lavage rarely provide benefit.  Ann Emerg Med 2010 Apr;55(4):365-6.  PubMed
              • Anderson RS, Witting MD.  Nasogastric aspiration: a useful tool in some patients with gastrointestinal bleeding.  Ann Emerg Med. 2010 Apr;55(4):364-5.  PubMed
              Major Studies ReferencedNB:  I haven't found any RCTs on NGL in UGIB and the major studies are in patients admitted to the hospital (high suspicion/obvious bleed or sick).
              Witting et al
              • Retrospective records review of patients admitted through the ED with a code for GI bleed
              • n=220
              • Excluded patients with hematemesis
              • Retrospective, cohort of patients admitted to hospital with code consistent with UGIB
              • n=633 
              • Conducted a Propensity analysis (attempt to mitigate selection bias)