This week, Annals of Internal Medicine published a well written editorial about how Australia has managed to significantly reduce gun violence with a nod to the measures it took back in 1996. It’s unfortunate the physician base within the US hasn’t been more vocal to advocate on behalf of patient safety or even prevention. The attempt to combat gun violence with more guns (and arming more people) doesn’t seem to be working. It would be awesome to see stronger advocacy from a well organized group of physicians who have the ability to exert considerable influence. Until US physicians advocate more vocally, it appears to be an opportunity lost.
This is part of a continuing series exploring the Confusing array of changes to healthcare and identify the Opportunities for our specialty. The goal is to give you three things:
There is a tidal wave that is coming. The baby boomer generation (those born 1946-1964) are now entering retirement age. Combined with increases in life expectancy it is causing an unprecedented "graying" of the United States and most other industrialized countries.
Dr Brian Burns, Dr Karel Habig & Dr Cliff Reid of GSA HEMS, NSW Ambulance. What are they looking at so seriously?
Dr Peter Sherren and SCAT Paramedics from the GSA HEMS team, first up in the inaugural Aeromedical Simulation Cup 2012
The winning team ( Dr Andrew Pearce with flight nurses) from MedSTAR, Adelaide in 2012. Come and see them defend their crown in August 2013, Melbourne!
AIR SUPPORT- THE VITAL LINK, CONFERENCE WEBSITE
Jim DuCanto demonstrates how he intubates via the AirQ SGA using the AirVu optical stylet. This is done using gaseous and local anaesthesia alone WITHOUT RECOURSE TO PARALYTICS OR IV INDUCTION AGENTS
This patient came in with abdominal pain. An upright chest Xray was ordered to eval for free air. Can you see any abnormalities?
What’s wrong with this picture? (HINT: you may need to zoom in on the cardiac silhouette and mediastinum to see the abnormality)
Answer to follow.
Author: Russell Jones, MD
Image Contributor: Aaron Hougham MD
From the SCCM EM Section with my friends Tim Ellender and Lil Emlet. If yo are thinking of going for critical care fellowship, check it out ASAP
You just read the post: Vodcast on Applying to Crit Care Fellowship from EM from EMCrit Blog - Emergency Department Critical Care.
Citation | Study Design | N | Drug | Calcium Form/Dose | Results |
Weiss AT, et al. Int J Cardiol 1983; 4:275-84. | Prospective | 13 | Verapamil | Calcium gluconate 1 gm | SBP ↑ 5 mm Hg |
Roguin N, et al. Clin Cardiol 1984; 7:613-6. | Case series | 2 | Verapamil | Calcium gluconate (pediatric pts) | No hypotentsion |
Haft JI, et al. Arch Intern Med 1986; 146:1085-9. | Sequential study of 2 treatment protocols | 50 | Verapamil | CaCl 1 gm | SBP ↑ 2 mm Hg |
Sequential study of 2 treatment protocols | 5 | Verapamil | Calcium gluconate 1gm | SBP ↓ 12 mm Hg | |
Stringer KA, et al. Drug Intell ClinPharm 1988; 22:575-6. | Case Report | 1 | Verapamil | CaCl 1gm | No hypotension |
Barnett JC, et al. Chest 1990; 97:1106-9. | Prospective report of protocol | 19 | Verapamil | Calcium gluconate 1gm or CaCl 1gm | SBP ↑ 4 mm Hg |
Kuhn M, et al. Am Heart J 1992; 124:231-2. | Retrospective chart review | 18 | Verapamil | Calcium gluconate 3gm or CaCl 1gm | No hypotension |
Miyagawa K, et al. J Cardiovasc Pharmacol 1993; 22:273-9. | Sequential study of 2 treatment protocols | 7 | Verapamil | Calcium gluconate 3.75 mg/kg | SBP: no change |
Kolkebeck T, et al. J Emerg Med 2004; 26(4):395-400. | Prospective, randomized, double-blind, placebo-controlled | 34 | Diltiazem | CaCl 0.333 gm | SBP ↓ 8 mm Hg (placebo had SBP ↓14 mm Hg) |
My residency program discussed the EMS chapters in Rosen’s tonight and went over the START protocol for triage in mass casualty incidents.
For the unacquainted, START stands for Simple Triage And Rapid Treatment. This protocol aims to make triage extremely fast and simple to allow first responders to quickly assess large numbers of patients. Triaged patients are clearly marked with colors (black = dead, red = immediate attention, yellow = delayed attention, green = minor injuries).
As a mass casualty protocol may need to be taught to a large number of people quickly, it also needs to be intuitive. Unfortunately, in looking over the description in Rosen’s, I didn’t find that to be the case. Anyone that has read about this system in the past would have reviewed a flowchart that looks something like this:
Like some of the other Tiny Tips that I have/will publish, it is unlikely that emergency physicians will need to memorize this. However, it certainly could appear on a resident’s Board exam. My goal with the Tiny Tips is to find a way to remember things for these exams that I do not find intuitive. This flowchart definitely fit the bill.
A quick search found me the mnemonics 30-2-Can Do and RPM (Respirations, Perfusion, Mental Status) to help remember the criteria. This seems like a reasonable way to teach the system, but it didn’t stick with me very well. Instead, I decided to remember it by sticking with the absolute basics because the flowchart is really just the ABC’s complicated by arrows and colors. Here’s what my revised START flowchart looks like:
While this method of remembering the START triage system still requires memorization of some findings, I found that merging it with my regular assessment system (ABC!) was more intuitive than trying to remember an incomplete rhyme (30-2-Can Do) and relating those numbers to speed (RPM). Using the START protocol this way, the relationship between the criteria and the assessment of the ABC’s can be clearly seen.
This memory device, as well as the rest of the Tiny Tips, have been made into flashcards that can be downloaded and used as outlined on the Boring Cards page. Check them out!
The post Tiny Tips: START Protocol for Mass Casualty Triage appeared first on BoringEM and was written by Brent Thoma.
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‘Just a Routine Operation’
…….perhaps the sentinel case that finally brought ‘team work’ and ‘human factors’ (CRM) to the attention of healthcare.
Watch and learn!
The stage is set
In preparation for #IETMC13 the International Faculty Development teaching course – the #MeduBrawl has begun.
Traditional learning versus the flipped classroom, versus social media and FOAM. Gloves are off as we prepare to better understand the best teaching modality for medical education…
The post Teach, fight, tweet… appeared first on Life in the Fast Lane medical education blog.
Trans-venous Pacing Wire Insertion
Is your patient bradycardic & compromised?………..you might need to know how to place one of these…..
In addition to the video consider ‘visualisation’ during placement:
Ok, I need a break from all the Women’s Health. More still to come on Women’s Health this month. But I recently recorded another episode of “Lessons Hard Learned” with my mate Dr Tim Leeuwenburg of KI Docs.
This is a discussion mainly about drug errors, systems errors and human factors in the commonest errors (drug / medication errors) we make in our daily practice.
WARNING: this episode contains some comments which are in very poor taste indeed.
i would have edited them out, but it is Tim….. He is uneditable
Enjoy
Sengstaken Blakemore or Linton Tube Insertion
……..bleeding varices?….you might need to know this!
https://www.dropbox.com/s/69ennbgu763pnwf/Sengstaken%20Blakemore%20or%20Linton%20Tube%20insertion.pdf
Cliff Reid and colleagues presented this poster at the Aeromedical Society of Australasia and Flight Nurses Australasia 2012 meeting in Cairns
Scientific poster on the intubation technique developed by Cliff Reid and colleagues
Here is the paper that Cliff and colleagues published
3.5 out of 5 stars
The New Crisis in Confidence in Psychiatric Diagnosis. Frances A. Ann Int Med 2013 May 17 [Epub ahead of print]
Allen Frances, professor emeritus and former chairman of the Department of Psychiatry at Duke, has long argued that the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would be a seriously flawed product. He much credibility on this issue — perhaps along with potential bias — since he chaired the task force that produced the previous edition, DSM-IV, in 1992.
In this short but interesting article, appearing just as DSM-5 is becoming available, Dr. Frances summarizes his objections. Basically, he argues that DSM-V will accelerate the already alarming trend of psychiatric diagnosis inflation, resulting in an epidemic of false-positive diagnoses and use of unnecessary, potential harmful medications. He points out that this process has been happening at least in the 2 decades since DSM-IV was published:
In the past 20 years, the rate of attention-deficit disorder tripled, the rate of bipolar disorder doubled, and the rate of autism had a more than 20-fold increase.
DSM-5, Frances contends, will make things much worse:
The DSM-5, the recently published firth-edition of the diagnostic manual, ignored this risk and introduced several high-prevalence diagnoses at the fuzzy boundary with normality. With DSM-5, patients worried about having a medical illness will often be diagnosed with somatic symptom disorder, normal grief will be miidentified as ajor depressive disorder, the forgetfulness of old age will be confused with ild neurocognitive disorder, temper tantrums will be labeled disruptive mood dysregulation disorder, overeating will become b eating disorder, and the already overused diagnosis of attention-deficit disorder will be even easier to apply to adults thanks to criteria that have been loosened further.
In addition, Frances charges that the entire process that produced DSM-5 was corrupt:
I found the DSM-5 process secretive, closed, and disorganized. Deadlines were consistently missed. Field trials produced reliability results that did not meet historical standards. I believe that the American Psychiatric Association (APA)’s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product. The APA refused a petition for an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations. Publishing profits trumped public interest. . . .
The issues surrounding DSM-5 have potentially enormous consequences for the field of medical toxicology, since diagnostic inflation may very well result in an exponential increase in prescribing psychotropic drugs such as stimulants and antidepressants.
For those interested in this important topic, Dr. Frances’s lecture “Diagnostic Inflation: Does Everyone Have a Mental Illness”, given last year at the University of Toronto, is worth checking out:
I'm not 88 or 95 years old. I don't know what its like to be at that age. One thing I wonder about is why do a lot of the very elderly put themselves through all of these complicated medical procedures? Like being resuscitated and going through a hypothermia therapy. The risk of TPA. Being on dialysis. Taking a chance on a major operation. 
RAND did us a huge favor here, documenting the shifts in styles of care and validating most of what we’ve said anecdotally.
http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf
Enjoy!
Related posts:
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You may have seen these strange pixellated squares at a recent academic conference on a a poster presentation, or perhaps on printed media and wondered what they are. Well, they are QR codes. Great… what’s QR code? Read on… QR codes are essentially the hybridization of barcodes and hyperlinks (website address).
QR stands for Quick Response. QR is actually a trademarked version of matrix barcodes (AKA 2D barcodes) for designed for the automobile industry in Japan (a subsidToyota) as a machine readable label that revealed information when scanned. The image encodes any type of data – pictures, words, characters etc,. They are able to be read quickly (hence the name) and can encode/store more data than a traditional UPC barcode. The black square dots are arranged on a white background in a unique pattern that is then read by an imaging device (the camera on your cell phone) which then is processed using a designated application that interprets the data. This data is extracted, and the application can display data or direct the user to a website.
The data encoded in a QR code for those nerdy enough to care
Well, first you’ll need something to direct the QR code towards. That could be any website or even an email address. Here are some examples:
YouTube Video
Google Maps Location
FourSquare
App Store Download
iTunes Link
Dropbox
Telephone Number
Skype Call
SMS Message
Email Address
Contact Details
Event (VCALENDAR)
Wifi Login (Android Only)
Paypal Buy Now Link
Once you’ve decided what you’re going to link, then you’ll have to generate a QR code. There are lots of free websites that will do this for you. And essentially they all ask you to input a web address etc,. then spit out an image file that you can insert wherever you’d like. Here are a few that you can check out:
QR Stuff: Allows you to select what type of data you input, but is limited in the number of uses for free
Kaywa QR Code: Another site with free options – this time unlimited
QR Code Generator: I used this one to create an example that directs you to my educator portfolio. It allows you to automatically generate an embed code so that you can insert it into a website.
Once you’ve got a QR code, or if you encounter one, you need a way to “read” it. Fortunately there are a number of applications (free and paid) available for your mobile device. Once you pick one and install it you’ll use the application and your smart phone’s camera to capture the image of the QR code, and then the application itself will direct you towards the linked resource.
Though these codes seem to be everywhere their adoption, at least according to some sources, is lacking. See this infographic for a handy summary. Why have they not been adopted? Well, you need to download a separate app, and then remember to open it. Though this only takes 30 seconds – wer are impatient craetures. The public’s knowledge of the use and utility of QR codes is still limited. And finally, using a QR code to simply link you to a corporate website isn’t actually stretching the potential of the tool. It is therefore up to the user to figure out unique ways to take advantage of QR codes.
The post Tech Tuesdays: QR Codes appeared first on PEM Blog.
Welcome to the 104th edition!
The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.
http://www.youtube.com/watch?v=SqkeRWwH760
http://www.youtube.com/watch?v=5dRlApLVuDY
The Trauma Professional’s Blog
http://www.youtube.com/watch?v=fMvi_MnUqt0
The SMACC2013 opening videos have been released- and the are awesome. Check them out on YouTube SMACC Channel or listen to them on iTunes.
Check out:
Scott Weingarts opening talk on “The Essence of Critical Care”
http://www.youtube.com/watch?v=3QcGom3rslg
And the amazing Cliff Reid on: ‘Making things Happen”
http://www.youtube.com/watch?v=PXAMlCwQAyY
GMEP Video of the week:
This weeks video is by Andy Neil from Emergency Medicine Ireland with his video on social media he gave at the Workshop for EMS Gathering:
Emergency Medicine and Critical Care Blogroll
Emergency Medicine and Critical Care Podcasts
123Sonography.com — Academic Life in Emergency Medicine — Adventure Medicine— A Life at Risk — All LA Conference — Al Sacchetti’s Youtube — Bedside Ultrasound — Better in Emergency Medicine —boringem—Broome Docs— CCM-L.org — CLIC-EM — Critical Care Perspectives in EM — Dave on Airways —DrGDH — Dr Smith’s ECG Blog — ECG Academy — ECG Guru — ECG of the Week—ED Exam —ED-Nurse— EDTCC — EKG Videos— EM Basic — EM Core Content — EMCrit— EM CapeTown — EMDutch — Emergency Medical Abstract —EM Journey—EMERJENCYWEBB –EmergencyLondon — Emergency Medicine Cases — Emergency Medicine Education —Emergency Medicine News— Emergency Medicine Ireland — Emergency Medicine Tutorials—Emergency Medicine Updates —EM on the Edge —Emergucate —EM Journey — emimdoc — EM Literature of Note — empem.org — EMpills — Emergency Physicians Monthly — EM Lyceum — EMProcedures — EMRAP — EMRAP: Educators’ Edition — EMRAP.TV — EM REMS — ER CAST — EXPENSIVECARE — Free Emergency Medicine Talks — GMEP — Gmergency!—Got Resuscitation— Greater Sydney Area HEMS — HQmeded.com — ICU Rounds — Impactednurse —Injectable Orange — Intensive Care Network — iTeachEM — IVLine — keepcaring — Keeping Up With Emergency Medicine — KeeWeeDoc — KI Docs— LipheLongLurnERdok — MDaware — MD+ CALC — MedEDMasters — Medical Education Videos — Medicina d’urgenza — Medicine for the Outdoors — Micrognome — Movin’ Meat — Neurointensive Care — Pediatric EM Morsels — PEM ED — PEMLit —PEMTweets Blog — PHARM — Practical Evidence — Priceless Electrical Activity — Procedurettes — PulmCCM.org — Radiology Signs — Radiopaedia — Resus.com.au — Resus.ME — Resus Review — RESUS Room — Resus Room Management — Richard Winters’ Physician Leadership —ruralflyingdoc — SCANCRIT — SCCM Blogs — SCCM Podcast — SEMEP — SinaiEM — SinaiEM Ultrasound — SMART EM — SOCMOB — SonoSpot — StEmylns — Takeokun — thebluntdissection—The Central Line — The Ember Project —The Emergency Medicine Resident Blog — The NNT — The Poison Review — The Sharp End — The Short Coat —The Skeptics Guide to Emergency Medicine — The Sono Cave - The Trauma Professional’s Blog — underneathEM.com — ToxTalk — TJdogma — Twin Cities Toxicology — Ultrarounds — UMEM Educational Pearls —Ultrasound Podcast — Ultrasound Village
The post The LITFL Review 104 appeared first on Life in the Fast Lane medical education blog.
St Emlyns - Meducation in Virchester #FOAM
Many Emergency Physicians are deeply committed to education. Many will be also be instructors on life support courses. This will often be done in their own time and at not inconsiderable personal sacrifice….
In the current climate we are also facing some pressures in job plans and rosters to justify our efforts and activities beyond just seeing patients on the shop floor. Now obviously seeing patients is what we are all about, but in order to do that we need to develop ourselves, our staff and our departments. Education is key to this and I’m a fan of accrediting those efforts externally as ‘evidence’ for revalidation and appraisal.
So, I am delighted to announce that the Academy of Medical Educators (AoME) in the UK has approved the Generic Instructors Course (GIC) course as an equivalence route for membership of the Academy. In the past membership was obtained by completing an application form involving a fair bit of reflective writing and evidence. It was good, but it did take a bit of work and I think it put a lot of people off applying. The new automatic approval process means that if you have passed the GIC you will be automatically accepted as a member of the Academy.
(Bonzer as out Antipodean colleagues might say – Ed)
Bonzer indeed, though it is worth stopping and thinking about the benefits. There is a cost of course which is pretty high in my opinion. If you are part of an organisation with corporate partnership then you pay the reduced rate (ALSG is, as is my own trust). It’s also tax deductable, so if you are lucky enough to pay lots of tax then it’s considerably less again.
| Membership |
£225 (£150*) (Salary>60k pa) |
£110 (£73*) (Salary <60k pa) |
* lower rate applies for corporate partners & ALSG is one.
So, apart from the benefits of external validation and a signal to others that you are a ‘professional educator’ (Ed- really???) what else is in it for you? It’s worth having a look at the following document from the Academy itself to explain more, but in essence this is a move to professionalise and recognise education as a specific skill and role. If you are interested in education this may well prove valuable in the future.
Why you should join the Academy
If you have not done a GIC course, then don’t worry you may well still be eligible for membership or even fellowship of the academy through the usual routes of application. A number of workshops on applications are planned by the academy around the country and you can attend one of those.
Ed – What if I did my GIC with the Resus council??
Good question. As I understand the situation at the current time this is a specific arrangement with ALSG. I don’t think the Resus council is a corporate partner, and I don’t think they have been through the approvals process. I would check with them directly if you want to know more.
My own conflict of interest is perhaps that I am a Fellow of the Academy and was for a brief time a member of Council, though that ended last year. I’ve also facilitated some workshops on joining the AoME so feel free to take my comments with a pinch of salt. I’ve also done loads of work with ALSG including a little to do with getting this process approved. The major thanks must go to the fabulous Sue Wieteska of ALSG who has yet again done an amazing job in supporting the hard working instructors of ALSG. Thanks also to Mike Davies and Kevin Mackway-Jones & everyone else who has contributed.
The post Good news – AoME + GIC = Membership. St.Emlyn’s appeared first on St Emlyns.
St Emlyns - Meducation in Virchester #FOAM
Thanks to Karim for a heads up on this one. Just a quick post this time, but another paper looking at the use of tranexamic acid in trauma and in this case the potential synergistic effect of cryoprecipitate together with TXA in trauma patients.
So, what of the paper? What can it tell us about the management of traumatic coagulopathy in the resus room? Well, for starters, read the abstract below and follow this link for the full paper (if you have journal access) which is now available on the JAMA network.
Now, as this was observational it is perhaps not surprising that these groups appear to be slightly different at baseline. Perhaps not in the way you’d expect (I was surprised to see that the group with the highest % of SBP<90 were the ones given neither for example), but they are different at face value and also statistically. Interesting that as it may well influence the results.
The thinking behind the study is that Cryoprecipitate is a rich source of Fibrinogen which is rapidly exhausted during major bleeding. If that is replaced in conjunction with TXA with inhibits Fibrinolysis then perhaps they can be synergistic in effect. Sounds good to me – but does it work in practice?
The main outcome in this study was mortality at hospital discharge.
So, another trial is another from the same group that put the MATTERS trial together. The results are really interesting but the design and setting limit the applicability to my practice. Perhaps we need to keep thinking but wait a little longer to see how this works in the civilian population. Back to you Karim….
So, let’s look at this with interest, and wait to see what CRYOSTAT tells us. Looking at the protocol I think it will give us the answer we need, but I’m not yet sure when we might see the findings.
The post JC Cryo + TXA for trauma apparently it also MATTERS. St.Emlyn’s appeared first on St Emlyns.
The SMACCalanche has begun!
Cliff Reid (@CliffReid) was without a doubt one of the superstars of SMACC. His talk ‘Making Things Happen’ is a lucid, practical and often times hilarious guide to the inner workings of a leading a great resus. The good news is that if you missed it you can now check it out on the SMACC podcast or watch the video on Resus.ME. Cliff’s ‘Making Things happen’ page on Resus.ME is a gold mine of references and resources supporting the talk.
Go on, check it out, make it happen!
The post Making Things Happen appeared first on Life in the Fast Lane medical education blog.
