August 2016: Journal Club with Justin & Casey [JC:JC]

We are back – Dr Justin Morgenstern has returned for the second instalment of the First10EM Journal club.

We fly through as many papers as we can in a podcast to bring you some of the info you need… and a bit you probably don’t.

REMEMBER: we are just a couple of guys with too much time on our hands.  You are a clinician. Please, please THINK CRITICALLY.    Read them and judge them for yourself.  Listen HERE:

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You can read Justin’s written version of his analysis over at the First10EM blog if you are not really an audio person.

Here are the PDFs of the papers discussed this month:

OK Download the podcast and have a listen.  Let us know your thoughts and anywhere that you have a divergent perspective.  We love to learn.

Cheers

Casey & Justin

Lessons Hard Learned: Dr Seth Trueger

I caught up with my old mate from Chicago, Seth Trueger to discuss a case.

This is a really great case – as it is one with soo many lessons for us all to learn.  It is a case of a “frequent flyer” – one of those patients that turns up on every third shift with all the usual complaints.  Every ED in the world has a collection of these folk.  They are usually living a harsh life with alcohol, drugs, homelessness and mental illness being common themes.

They are hard to treat.  We tend to try and avoid them and yet… they are at very high risk for all of the bad things that can and do happen to people about there on the streets.

So have a listen.  Consider the last time you saw one of your ‘regulars’ and how you too could have missed an important diagnosis.

DIRECT DOWNLOAD

Tell us about your experiences with these scenarios

Cheers

Casey

Clinical Case 133: POCUS Perils [and the Debiasing Dance]

I am a mad point-of-care ultrasound [POCUS] fan.  I scan pretty much every patient that I can.  I do this to sharpen my diagnostic skills, practice and to explore new utilities of the humble ultrasound.  However, as my POCUS practice has matured and I have made countless errors; I am learning very slowly to do POCUS in the right order.  What is the right order?  Well, POCUS is a great tool.  But like any diagnostic “test” it needs to be interpreted in the fullness of the clinical context.

Too often lately I have been catching myself doing “spot POCUS” on request from my colleagues.  Usually in the middle of a busy shift a mate will call me over to their patient and say: “Can you look at this?”  At which point I wander into the cubicle, introduce myself #hellomynameisCasey and scan the troubled area…  This is BAD MEDICINE!  The myth is that if you are a super-keen, proficient sonologist that you will find the underlying problem and Presto!  However, what often happens is an inadequate, limited scan followed by some head-scratching and then a retreat into history and clinical exam…  or onto CT which may / may not be necessary.

So my new mantra is: “Always start with the story, feel with your fingers, look at the things that the probe cannot see and then scan.”  So today’s case is a cautionary tale.  One which I feel illustrates the problems and perils with “SPOT POCUS”.  OK onto the case….

It is late Sunday afternoon and everyone is keen to get home, and onto the beach.  That is why we live here in the tropics.  Just as I am tidying up the paperwork and sending my last few patients home my mate asks me to pop up to the inpatient ward to “have a look”.  Of course, this means – scan.  The story is as follows:

Jerome Jenkins is a 35 year old local who is a frequent flyer in the ED.  HE drinks to excess a lot of days and can often be found sleeping on the waiting room floor.  Jerome tends to be tolerated as he rarely causes too much fuss and is a happy drunk.  Over the years he has suffered his share of traumas and complications associated with his lifestyle including pancreatitis, retinal detachments and a few seizures.  Yesterday – Saturday – he came in very drunk.  Blood alcohol = 0.450 and unrousable.  This is not unusual. However, he woke complaining of lower abdominal pain.  Although he is usually “turfed” to the Sober-Up shed on waking, this time his Obs were a bit off and it was decided to keep him in for some observation and work up if he remained in pain.

Fast forward to the next morning – and Jerome is now clinically sober and complaining of lower abdo pain.  His belly is mildly distended and he has soaked up a bit of morphine.  He is usually pretty stoic and lives a hard life – so this is atypical.  His Obs are normal aside from a BP of 95/60.

Of course, I know none of this story when I get a call to come up and “do a bladder scan”.  Jerome hasn’t passed much urine all day, he has increasing spuprapubic pain and seems a bit distended.  The automated “Bladder scanner” used by the RNs on the ward is reading his bladder volume as 2100 ml!  That seems a bit odd.  So I was asked to come and do a measure…. so here is something like what I saw:

Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 9790

Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 9790

So I was very proud of my interpretation when I saw this…

The bladder is moderate size [measured at 400 ml]and there is free fluid in the adjacent pelvis.

Clearly I am sooo much smarter than the “auto Bladder Scan” machine!  It was confusing extravesicular fluid for urine… dumb machine.

Now, being a very average doctor who was not in anyway “invested” in Jerome’s care. I made a quick verbal report to my mate.   “He has a heap of free fluid… not sure why… does he have ascites?”  To which my colleague replied: “yeah, I think so.  His liver function has gone right off since we last checked.  His ALT is through the roof..”  In retrospect these are a pair of  reciprocating confirmation biases… a perfect storm for disaster.

So lets go back and look at this story the way I like to nowadays.  Lets perform my little “Debiasing Dance” that I have learned to do in the few years.  Hat tip to Dr Rob Orman [ER CAST] and friends for this.

The Debiasing Dance is best done in private.  The first step is to get somewhere quiet, a hallway or tearoom is fine. In honesty it often happens in the loo.  The key is to get out of the clinical area where there is too much data flying around for just a few minutes.  Try and reduce the case down to these bare basic elements:

  1. Who is the patient?  Fit ‘n young or old and frail.  Immunosuppressed or at risk for other problems.  This is another way of estimating the “pretest prevalence” of a whole raft of possibilities.  In this case Jerome is young but at risk for lots of badness, infections and plenty of “unknowns”.  The story is woefully incomplete.  The last 5 times I met him he had been assaulted – so… trauma ought to be up there on the list!
  2. What is happening right now?  What are you / or the other clinicians worried?  Why were you called to see them?  Often this is because of abnormal Obs, a new symptom or clinical deterioration.  Try and block out all that has come before; stuff that might falsely ‘explain’ the current status.  The classic here is “Oh don’t worry about that lowish BP, he is always like that...”
  3. What do we know objectively?  We often attempt weigh a heap of information in these situations.  Some of it is hard, objective and irrefutable. However, some info is soft, subjective opinion or based on hearsay.  The former needs to be explained, the latter can be a source of bias.  Try and weigh these appropriately and deal in the objective.  What features of the case stand out when examined through an impassive lens.
  4. The retrospective triad.  I am not sure if somebody smarter than I invented this concept.  Please let me know if they did.  The retrospective triad involves running the case backwards and thinking: “The patient had X, Y and Z… hence it was obvious that the diagnosis was THIS.”   In Jerome’s case if we run through steps 1 – 3:
    1. Jerome is an alcoholic who lives rough and gets assaulted frequently.
    2. He has free fluid – which is new as far as we know
    3. He has poor urine output and lowish BP (usually his “low BP” is measured when he is extremely intoxicated in ED)

The retrospective diagnosis seems obvious, but of course it is usually clouded by a heap of irrelevant, misleading and biased data.  Try and focus on the facts that rise above the fog.  Then one needs to be imaginative and ask yourself “what if…?”  as sometimes the third spoke of the triad is hiding in the haze of available information.  Often this is as simple as going back to the bedside and asking that one pertinent question or just looking where others have not.  For example, does Jerome have a massive bruise in his perineal area as a result of a well placed boot?

The real trick to doing the debiasing dance is to be able to imagine yourself looking back in a week and doing an M&M presentation (or writing to your MDO lawyer) and then apply that imagined hindsight in a prospective manner.

So back to the case….

Jerome sustained a urinary bladder rupture – an intraperitoneal one – which is a bit rare.

Most intraperitoneal bladder ruptures result from trauma to the bladder (often blunt) when the bladder is full. So the working theory is that Jerome was passed out drunk with a bladder full of beer when he was kicked / punched etc to the lower belly…. POP.

If you want to read more and see some pretty pictures of this injury then pop over to Radiopedia and check out a few other cases.

OK.  Hope you learned something from case 133.  Big shout out to Dr Nick Gilbert – my super Resi who demanded more clinical cases on the blog.  I always try to keep the locals happy!  Get your groove on and try the Debiasing Dance, worse case is you waste a toilet break and look a little silly if you actually dance in the tearoom.

Weird-Dancing-Man-Funny-Gif-Image

Casey

_Case 843_01

Old Dog, New trick… teaching procedural skills

The news this week for me – I learned a new procedure!  Yes, after many years of doing things that I had learned and practiced I found myself in the situation where I could have a crack at something new.   This was an interesting experience for me because :-

  1. It has been a while since I tried to do something unfamiliar.
  2. It was an interesting exercise as a teacher to go back to being the novice, to feel the pressure of that moment.
  3. There is something deeply satisfying about acquiring a new arrow in one’s skills quiver
  4. I learned [from the inside] about how to better teach practical procedures.
  5. I was on the awkward side of the tension between letting the novice “have a go” and yet keeping the patient safe.

So what was this new skill?  I learned how to perform a subtenon eye block.  This is a relatively simple anaesthetic technique that appears to be quite dangerous and painful, but is actually not so bad.  If you want to see it in action… check out this clip from UltrasoundBlock.com [edit: no ultrasound required!].  Simple enough to do, but requires the use of unfamiliar instruments, in a very sensitive part of the body with a patient whom is wide awake.

The big difference between my learning this skill and the previous learning in procedures such as epidurals etc [aside from about 15 years] was that I had a mental structure as to how I was going to make the most of my mentor’s availability to teach.  Having been exposed to the SETT UP technique, and trying to use it with my students it was great to be able to apply it to myself.

I basically used the 5-step technique described by George and Doto in 2001, with a bit of a FOAMed twist.  Here is the five-stage approach:

  • Conceptualisationthe learner must understand why it’s done, when it’s done, when it’s not done, and the precautions involved.

This can be pulled from any anaesthesia or ophthalmology textbook.  There is a list of indications, contraindications and the stuff you need to tell the patient before performing the procedure.  Review the basic sciences.  Anatomy is important to review as this is not an area most ED docs have to contemplate often.

  • Visualisationthe learner must see the skill demonstrated in its entirety from the beginning to end so as to have a model of the performance expected.

This is where FOAM comes in  – one can watch dozens of videos.  I watched it done by multiple practitioners, using a variety of techniques on a range of mammals (dogs, horses… all get cataracts).  The key is to see it done in multiple ways in order to get a feeling for the varied and acceptable techniques.  This is great for building confidence.

  • Narrationthe learner must hear a narration of the steps of the skill along with a second demonstration.

Once again – pop onto Google / Youtube or any of the great FOAMed resources.  There are plenty of narrated videos showing it stage by stage. However, the best narration occurs when your teacher performs it live with you watching.  Connecting the audio with the visual in the flesh seems to lay down the memory more effectively.

  • Verbalisationif the learner is able to narrate correctly the steps of the skill before demonstrating there is a greater likelihood that the learner will correctly perform the skill.

This step is important to do immediately prior to performing the skill.  Better than simple verbalisation is what Cliff Reid calls “cognitive simulation” – mentally rehearsing the steps in one’s head.  For this procedure I was holding imaginary scissors in my hand and rolling along an imaginary eyeball to rehearse the motor action involved.

  • Practicethe learner having seen the skill, heard a narration, and repeated the narration, now performs the skill.

Practice, practice and more practice.  I was lucky enough to be able to repeat the procedure six times in one day.  Importantly, I insisted that my teacher continue to observe my technique and provide feedback.  The old “see one, do one…” is a myth. Usually it is the little things – the tips that experts do automatically, and only recall when they watch a novice perform them.  One patient’s block was technically challenging and I was required to troubleshoot with my teacher.  This is probably one of the most crucial steps – learning what to do when the plan goes awry.

So after a day of being the novice I have developed a few insights.  In order to teach a procedure – we should be walking our student through the above stages in order to make the most of the opportunity and maximise the chances of the skill ‘sticking’.  Unfortunately,  in most places I have worked there is usually little deliberate practice or any of the steps above.  Certainly this is how I learned most of my skills – trial, error and quite bit of patient harm I imagine.

To teach a skill the ideal mentor should:

  • have mastery of the skill.
  • be able to perform the skill with confidence and clarity.
  • be able to articulate the subtleties of the technique
  • be able to deal with the complications and fix errors
  • have the patience to allow the learner to “faff”.  Faffing is how one develops the feel / touch required.
  • keep the patient calm and reassured.  Anxiety can be a real block to effective learning
  • be prepared to give practical, realistic feedback immediately after the task

So if you are a trainee – please be proactive when learning skills.  Simply waiting for somebody to teach you on an opportunistic basis is not ideal.  You need to have done steps 1, 2 and maybe 3 in your own time.  You need to be prepared to complete the steps when the opportunity arises on your shift.  Most importantly – become an active “cognitive simulator” – mentally rehearse your technique and steps to lay down the motor memory.

If you are a teacher of procedural skills – thank you!  I was very lucky to have a patient and confident mentor this week.  He allowed me to faff a little and feel safe.  Probably the thing that helped me the most during my supervised subtenon blocks was the kind voice beside me saying: ” great…  keep going… that’s it!” – simple words but they really help to build confidence.  Much more helpful than the silence we often observe in these tense moments.

Let me know if you have any pearls for teaching procedures.  What did your favourite teacher do that made the skills easy to learn?

Casey

Lessons Hard Learned: Dr Penny Wilson

Over the last year or so I have received quite a bit of mail / feedback asking about the “Lessons Hard Learned” series that I ran a while back on the podcast.  It was a project I really enjoyed doing, it allowed me to interrogate the minds of some super smart folk out there.

So, after a bit of head-scratching I have decided to give it another crack.  I am inviting a pile of FOAM friends back to the mic in order to learn the tough lessons that Medicine teaches us in life.   [BTW if you have a story or “lesson” you would like to share, and teach us all – just drop me a line on the email / contact box.]

So to kick off the new series of “lessons” I am very happy to invite Dr Penny Wilson – my friend and colleague from right here in Broome to share a story from her early days as a junior doctor.  There are some great lessons here for both JMOs and their senior supervisors alike.  Luckily, the structure of supervision in Australia has improve a lot in the last 10 years.  I think we have learned a few of these lessons the hard way.  However, I know that there are a few countries out there with systems that may still be learning these.  So have a listen.  DIRECT DOWNLOAD HERE

If you are interested in learning some Obs and Gynae pearls in podcast form – then check out Penny’s excellent podcast:  Bits & Bumps here.

Enjoy

Casey