TechTool Thursday 056 ReelDx

TechTool review ReelDx

ReelDx is a website that hosts videos of patient cases. Users can browse the videos and discuss the case management. It has been set up by a team of doctors and Health IT entrepreneurs in the US…It is Amazing

Website: – WebsiteFacebook - Twitter

Design

The ReelDx website is very well designed – it looks lovely and there has obviously been time spent working on the layout and graphics. It runs smoothly and all the cases are clearly laid out with great quality video recording. Loads quickly in chrome and firefox, but had some issues with earlier version of Internet Explorer on hospital networks.

User Interface

reeldx 1

ReelDx example case

Clinical Content

There is a rather large library of videos on there already, including over 310 Emergency Medicine cases and more than 430 Paediatric cases…which wins me over instantly.

  • Each case contains some basic information and background about the patient, including baselines obs.
  • The video is a recording of that patient’s presenting complaint usually with some history from the patient.
  • You can try to work out the diagnosis or click to reveal.
  • There is a concise section providing advice on differential diagnosis and management.
  • Some cases have an extra ‘Expert Commentary’ video, where one of the Reel Dx experts discusses the case in more detail.
  • There is a comments section for users to discuss the case.

See this case of a 10 year old boy with ear pain as a nice example

Security and Patient Confidentiality

  • There seem to be several hospitals in the US taking part in this and the website states that it is HIPAA compliant.
  • There aren’t any specific details on the site about what the consent process is for this.
  • It contains many fully identifiable patient videos so it would be interesting to hear more about this process

Cost

  • Currently FREE
  • …but there has been a huge amount of work developing this site, not sure how the ROI will work.

Overall

  • This is fabulous and free.
  • It really encompasses what is great about health IT and online education – it uses our day-to-day clinical work for broader teaching.
  • In addition the teaching is delivered in a way that looks great, is interactive, and encourages other people to join in.

This is the best new FOAM resource I’ve come across this year.

I only wish I had Google Glass and a hospital that might agree to take part….

//www.youtube.com/watch?v=yIICZogSlfg

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Top 10 Tips on Surviving Nightshift

I’ve been asked by a lot of people how to manage night shift and its little friend, sleep disturbance, so I thought I’d write down a few of the tips that I have gathered over the years. Would love to hear your coping strategies and tips in the comments section…

Going onto nightshift

1. Try to do something physical “the day before the day before”. Physical activity is good for your general wellbeing anyway, and it will set you up for a decent “pre-nightshift” sleep. I would go swimming, running, boxing or have a mega-housework blitz. Then get a decent amount of sleep prior to starting nights:

  • Method 1: Stay up really late (at least 3am – 6am) the night before (calling/Skyping mates in different timezones or a TV marathon can help) then sleep for the majority of the day before your first nightshift.
  • Method 2: Go to bed as usual the night before , sleep in until late morning, have a big feed for lunch then go back to sleep for an afternoon/evening nap.

On nightshifts

2. Drink water and eat food (bring real food, not just junk, and a big water bottle that you can reach for when you are writing notes). Drinking enough water is my absolute number one piece of advice. It’s hard to be high functioning when you are symptomatically dehydrated. (Same goes for a BSL of 1.8!)

3. Just like with day shift, caffeinating during the second half of your shift reduces your chance of sleeping when you get home. Plan your caffeine. Eg. bring a big plunger and invest in decent Peruvian coffee to have on arrival during handover, and at the halfway mark of the shift. (Sharing means your whole night team runs smoother & happier too!)

Between nightshifts

4. If you suddenly realise you are too tired to drive home, DON’T. Get a taxi or phone a friend. We don’t need any more post-nightshift road trauma (ask your seniors and they will all know of past incidents, one more is one too many).

5. Your body reacts to sunlight. Wear dark glasses home, and invest in cut-out curtains; or an eye mask. Avoid artificial light – constantly checking your phone or iPad because you can’t sleep will make it worse.

6. Most of us use noise (alarms) to wake up. So, if you need to sleep, invest in ear plugs.

7. Don’t use alcohol to help you sleep. It is a sleep inducer but it will disrupt your REM sleep which impacts on how rested and functional you are on waking.

8. Don’t commit to things during the day because daytime people expect you to – you are living their life in reverse. Eg: Delivery service*: “So, you’re on nights, you’ll be home during the day, we can deliver at 3pm.” Me: “So, when you’re on dayshifts, do you plan to wake up at 3am to let random people into your house?” [*insert “Rellies inviting you to lunch, a course from 9am -5pm, friends wanting a shopping date” etc]

Turning around

9. There are many turnaround styles to consider. Just make sure you get the amount of sleep you need before you go on to do other higher functioning after your nights.

    • Method 1: After post-nights breakfast, go home and have a four hour nap eg 10am-2pm. Potter about and get some daylight exposure, then go to bed at your usual time.
    • Method 2: Sleep for 36 hours (all day and all night). Have a glass of water, some carbs like crackers by the bed and a clear path between the bed and the loo. Consider DVT prophylaxis.

10. DO make sure you make the time and headspace for Post-Nights Breakfast. Critical Care rosters lend themselves to this and I’d argue that in any teams that do a round of nights together, this is an incredibly useful space to wind down; congratulate one another and reflect on ways to improve. I make a point of having a debrief, called “The Ceremonial Airing of Grievances”. Homer (Simpson) has a lot to teach us. Venting prevents explosion. Use the formal positive critique/Pendleton’s model/the “hashtag rant” – just make sure everyone on the team can identify any painful experiences, reflect on how awesome they are; and work out how to be more awesomer next time.

In all seriousness, please look after yourself as you navigate the nightshift rhythm. These are just things I have found helpful, there’s lots of advice out there – head online to search for more nightshift and sleep tips. If these things are not working, go and see your GP (yes, I have one of those, so should you) to discuss individual techniques and adjuncts for healthy amounts of quality sleep.

Sleep long, and prosper

The post Top 10 Tips on Surviving Nightshift appeared first on LITFL.

The LITFL Review 146

LITFL review

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

Welcome to the 146th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerBrilliant new series from Academic Life in Emergency Medicine highlights how successful people in EM work smarter. Posts from Michelle Lin, Victoria Brazil and Esther Choo. [AS] Want a simple, awesome and comprehensive guideline?…Check out these Guidelines for Paediatric Concussion [KG]

The Best of #FOAMed Emergency Medicine

  • Computers can’t be trusted to do simple calculations . . . at least not when it comes to the QTc duration. Stephen Smith discusses in a case of syncope and bradycardia. [AS]
  • With changeover of junior doctor’s looming in the UK, the EmergencyPedia team set out 10 fundamentals of how to impress in the Emergency Department. [SL]
  • Wonder how accurate your respiratory diagnoses are in the ED? The St.Emlyns team discuss potential to improve our practice following a recent publication on point of care ultrasound for the breathless patient. [SL]
  • A pharmaceutical company (Boehringer Ingelheim) suppressed data? Inconceivable! If you’ve fallen behind on the dabigitran controversy, Ryan Radecki gives a short commentary on the situation. [AS]
  • New LBBB = STEMI? Not always. New LBBB with > 5 mm discordant ST elevation = STEMI? Nope. Great case from Stephen Smith highlighting the fact that ST segment elevation increases with tachycardia and the importance of STE-S wave ratio. [AS]

The Best of #FOAMcc Critical Care

  • How should we care for the sick and trying to die pregnant patient? Haney Mallemat discusses the Critical Pregnant Patient on the All NYC EM Podcast. [AS]
  • More greatness from SMACC Gold: Scott Weingart weighs talks on Sepsis in New York:  Our first 15,000 patients, while Mark Wilson talks on Monroe Kellie 2.0. [SO]
  • Interested in ICU physiology, particularly heart-lung interactions? Jon-Emile Kenny from Vancouver has an excellent set of animated lectures at www.heart-lung.org. Check them out! [SO]
  • Trans-oesophageal echo. It’s complicated, bulky, and outside the remit of point-of-care use for resuscitationists. Or is it? Matt and Mike from the Ultrasound Podcast present a lecture on POC TEE/TOE by Rob Arntfeld: Part 1 & Part 2 [SO]

#FOAMPed Paediatrics

  • Sean Fox at PED EM Morsels reviews delayed diagnosis of foreign bodies. It might be just a cough, but consider asking about that peanut they choked on six months ago…. [TRD]
  • Don’t Forget the Bubbles reviews a recent paper on ketamine dosing in obese adolescents – are we giving them too much? [TRD]
  • Is loss of consciousness useful in determining which kids with minor head trauma need a head CT? Rory Spiegel delves into the PECARN data and discusses its limitations. [AS]
  • Kids are just little adults. At least when it comes to the first hour of sepsis management, Simon Carley argues to think of kids as little adults to prevent the paralysis induced fear that EM physicians who rarely treat kids can feel. [AS]

The Best of #FOAMTox Toxicology

  • Poisoned patients…….the next group of ED patients to benefit from the bedside US?  Dr Leon Gussow discusses the use of POCUS for the poisoned.  [CC]

News from the Fast Lane

  • Michelle is back with her masterful writing skills with a look at Nothing New Under the Sun….Will have you thinking and questioning your own small world! [KG]

Reference Sources and Reading List

 

The post The LITFL Review 146 appeared first on LITFL.

Research and Reviews in the Fastlane 041

Research and Reviews in the Fastlane

Welcome to the 41stedition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Ultrasound, Pulmonary, CardiologyR&R Hall of Famer Blue

Laursen CB, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomized controlled trial. The Lancet Respiratory Medicine – July 2014 PMID: 24998674

  • One of the first RCTs examining the utility of POCUS for ED patients presenting with dyspnea. Using a POCUS protocol performed by a single experienced provider, examining the heart, lungs, and deep veins of the LE, authors found significant improvement in their primary endpoint – the rate of correct diagnoses made at 4 hours. Though promising, these benefits did not translate into improvements in hospital or 30 day mortality, length of stay or hospital free days. Furthermore there was a significant increase in downstream testing in patients randomized to the POCUS group indicating there may be a degree of over-diagnosis that occurs with the introduction of such a protocol. (Rory Spiegel)
  • This is further evidence that POCUS of the chest may be of benefit in the ED. However, although this is an RCT there are some significant biases within it. Whilst I personally agree with the results and in all honesty I wish them to be true, there is not evidence here to firmly change practice. For me I would like to see more studies using a broader population base, multiple USS operators and larger numbers. (Simon Carley)
  • Recommended by: Rory Spiegel, Simon Carley
  • Read More: POCUS for the Breathless Patient (St. Emlyn’s) and ED Hocus POCUS . . . or Just a Hoax (EM Literature of Note)

The Best of the Rest

Emergency Medicine,RespiratoryR&R Game Changer? Might change your clinical practice

Righini M et al.Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.JAMA. 2014 Mar 19;311(11):1117-24. PubMed PMID: 24643601. [JAMA Full Text]

  • This study prospectively validated whether an age-adjusted D-dimer cutoff was associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. Compared with a fixed D-dimer cutoff, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. So if this is not your clinical practice already, maybe time to use age adjust d-dimer values?
  • Recommended by: Jerremy Fried
  • Read More: Age Adjusted D-Dimer Testing (REBEL EM)

Trauma, Resuscitation

R&R Game Changer? Might change your clinical practice

Harvey V, Perrone J, Kim P.Does the Use of Tranexamic Acid Improve Trauma Mortality? Ann Emerg Med 2014; 63(4):460-462. PMID 24095056 [Annals Full Text]

  • This is a review of the literature regarding tranexamic acid use in traumatic hemorrhage showing that tranexamic acid significantly decrease mortality in bleeding trauma patients, without significantly increasing serious prothrombotic complications if administered within 3 hours of injury. There is, however, no evidence of benefit in patients with traumatic brain injury. The authors recommend early treatment with tranexamic acid in trauma patients without isolated brain injuries who have or are at risk for significant hemorrhage and in patients who receive resuscitation with blood products, particularly if they require massive transfusion or have a high risk of death at baseline.
  • Recommended by: Anand Swaminathan

Critical Care, Pediatrics

R&R Game Changer? Might change your clinical practice

Kelleher DC et al.Factors affecting team size and task performance in pediatric trauma resuscitation. Pediatr Emerg Care. 2014 Apr;30(4):248-53. PMID 24651216

  • This study investigates factors associated with varying team size and task completion during trauma resuscitation. Video of 201 pediatric trauma resuscitations were reviewed and task completion was then analyzed in relation to team size using best-fit curves. Having 7 people at the bedside during a pediatric trauma resuscitation was optimal in patient management. Beyond this number, the investigators saw diminishing returns.
  • Recommended by: Cliff Reid
  • Read More: Resus Team Size and Productivity (Resus.Me)

Resuscitation, Renal

R&R Game Changer? Might change your clinical practice

Allon M et al.Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. Am J Kidney Dis. 1996 Oct;28(4):508-14. PMID: 8840939 [AJKD Full Text]

  • This is the paper that should have pushed people away from using bicarb in hyperkalemia, or at least started them towards researching it. Whereas insulin and albuterol are effective temporizing measures to shift potassium rapidly from the extracellular to the intracellular fluid compartments and thereby lowering plasma potassium acutely, bicarbonate by itself is not. But bicarbonate is believed to have a potentiating effect on albuterol and insulin. Using a prospective cross-over design, 6 treatment protocols combining bicarbonate, albuterol, insulin and saline respectively were investigated for acute effects on plasma potassium as well as blood bicarbonate and pH in nondiabetic hemodialysis patients. The resulst observations suggest that bicarbonate administration does not potentiate the potassium-lowering effects of insulin or albuterol in this patient population.
  • Recommended by: Justin Hensley

Pediatrics, Haematology

R&R Eureka

Singleton T et al.Emergency department care for patients with hemophilia and von Willebrand disease. J Emerg Med. 2010 Aug;39(2):158-65. PMID: 18757163 [JEM Full Text]

  • Heriditary bleeding disorders are reletively rare and most often are treated in out-patients-clinics. Emergency physicians rarely encounter them with the potiential for delays in diagnosis and administration of replacement therapy. In this great review of ED evaluation and management of hemophilia and Von Willebrand disease to outline some of the issues facing emergency physicians and the options available for the treatment of these patients.
  • Recommended by: Sean Fox

Wilderness Medicine, Pediatrics

R&R Landmark

Hwang V et al.Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med. 2003 Jan;157(1):50-3. PMID: 12517194 [JAMA Full text]

  • In this ten-year retrospective review of pediatric drowning and near drowning the prevalence of traumatic injury was low. In fact the authors only identified cervical spine injuries, and all but 1 patient had a clear history of diving. Use of specialized trauma evaluations may not be warranted for patients in drowning and near-drowning accidents without a clear history of traumatic mechanism. So not all submersion victims are trauma victims! If they are not a trauma victim, then do you and the patient a favor and remove the C-Collar.
  • Recommended by: Sean Fox

Trauma, Neurology, Neurosurgery

R&R Hot Stuff

Nishijima DK et al. Utility of platelet transfusion in adult patients with traumatic intracranial hemorrhage and preinjury antiplatelet use: A systematic review. J Trauma Acute Care Surg: 2012;72:1658Y1663. PMID 22695437

  • Preinjury use of antiplatelet agents (i.e. aspirin, clopidogrel) is common. Patients with ICH on these agents have higher morbidity and mortality. this systematic review reveals the lack of evidence to support or refute the utility of platelet transfusion in these patients. Physicians must weight the risks and benefits of a platelet transfusion in patients on antiplatelet agents who present with traumatic ICH.
  • Recommended by: Anand Swaminathan

Toxicology, Resuscitation

R&R Game Changer? Might change your clinical practice

Dries DJ and Endorf FW.Inhalation injury: epidemiology, pathology, treatment strategies. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:31 .PMID 23597126

  • Relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury or chemical products of combustion. In this paper, pathophysiology current treatment strategies and medical strategies under investigation for specific treatment of smoke inhalation (beta-agonists, pulmonary blood flow modifiers, anticoagulants and anti-inflammatory strategies) are reviewed
  • Recommended by: Soren Steemann Rudolph

Emergency Medicine, Resuscitation

R&R Eureka

Shokoohi H et al.Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med. 2013 Feb;61(2):198-203. PMID 23141920 [Annals Full Text]

  • A well-instituted US-guided peripheral IV program will indeed decrease rates of central line insertion. Among of 401,532 patients, 1,583 (0.39%) received a central venous catheter. During a 5-year study period the rate of central line placement decreased by 80% The decrease in the rate was significantly greater among non-critically ill patients than critically ill patients. Not groundbreaking but nice to have some solid evidence.
  • Recommended by: Seth Trueger

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’sR&R in the FASTLANEor if you want to tell us whatyouthink is worth reading.

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Pressure volume loop of the left ventricle

Basic Science in Clinical Context (BSCC) videos will be 2minutes long and in 2 parts.

  • Exam candidate answering a question (under exam conditions)
  • Professor providing a more detailed explanation (with transcript)

Below is an example of the process. Feedback greatly appreciated as we are still very early in the production phase of the project.

Question:

Please draw and describe the pressure volume loop of the left ventricle

Examinee response

Examiner explanation:

Pressure volume loop diagram

  • This pressure volume loop diagram represents the 5 phases of the cardiac cycle.
  • It makes more sense to start at the end of stage 4 of the cardiac cycle: isovolumetric relaxation and beginning of stage 5- ventricular diastole.
  • At this point, the end systolic volume of the LV is +- 50ml.
  • LV diastole begins, stage five of the cardiac cycle. This phase allows the ventricle to fill. Remember that atrial systole or phase 1 of the cardiac cycle occurs late in diastole and propels some additional blood into the ventricles-allowing the volume in the LV to reach around 130ml (this is the LV end diastolic volume)
  • At point “a” is when ventricular diastole ends, the mitral valve closes and phase 2 of the cardiac cycle or isovolumetric contraction begins.
  • At point “b”, the pressure in the left ventricle rises above the pressure in the aorta causing the aortic valve to open. Now begins phase 3 of the CC- ventricular systole. 70-90ml (80ml) of blood is ejected into the aorta. This is stroke volume.
  • At point “c” the pressure in the LV drops below that of the aorta and the aortic valve closes. The remaining volume/the end systolic volume in the LV is around 50 ml.
  • This allows you to work out the ejection fraction of the LV: 80/130=62%.
  • Now phase 4 of the cardiac cycle begins:  isovolumetric relaxation.
  • The pressure in the LV drops to below that of atrial pressure. Phase 4 ends and Phase 5 begins again.
  • Some pressure volume loop diagrams describe an additional line. This line represents the end systolic pressure volume relationship. (ESPVR). It is the maximal pressure that can develop by the left ventricle at any given LV volume.
  • This line becomes steeper/shifts left as inotropy/contraction increases and will flatten as inotropy/contraction decreases.

The post Pressure volume loop of the left ventricle appeared first on LITFL.

Basic Science in Clinical Context (BSCC)

We leave medical school liberated.

Free to insouciantly frolic through remedy meadows and deprecate nostrum – impassioned with the heady erudition of establishment edification.

Free from the trammels of institutional learning we throw off the shackles of theoretical knowledge and plunge into the limpid pools of practical skill acquisition.

In general we are blissfully unaware of the insidious but exponential decay of our theoretical knowledge as we enthusiastically acquire practical life skills. We are even less aware that on at least two occasions in the ensuing 10 years our cerebrum will be galvanised back into action to thwart the examination Leviathan.

LITFL is producing a series of asynchronous learning videos combining basic science knowledge with clinical context application (BSCC) to reduce the rate of theoretical knowledge decay, improve the sanity of trainees and reduce the examination induced divorce rate.

We are not looking to reinvent the wheel but be synergistic with the programmes already produced such as Anatomy for Emergency Medicine (AFEM) by Andy Neill.

As LITFL authors have the attention span of intoxicated decorticate gnats, we will limit our presentations to 120 seconds each. We record an exam candidate answering a question (under exam conditions) and then record the professor providing a more detailed explanation (with transcript)

Below is an example of the process. Feedback greatly appreciated as we are still very early in the production phase of the project.

Question:

Please draw and describe the pressure volume loop of the left ventricle

Examinee response

Examiner explanation:

Pressure volume loop diagram

  • This pressure volume loop diagram represents the 5 phases of the cardiac cycle (CC).
  • It makes more sense to start at the end of stage 4 of the CC-isovolumetric relaxation and beginning of stage 5- ventricular diastole.
  • At this point, the end systolic volume of the LV is +- 50ml.
  • LV diastole begins, stage five of the CC. This phase allows the ventricle to fill. Remember that atrial systole or phase 1 of the CC occurs late in diastole and propels some additional blood into the ventricles-allowing the volume in the LV to reach around 130ml (this is the LV end diastolic volume)
  • At point “a” is when ventricular diastole ends, the mitral valve closes and phase 2 (of the CC or isovolumetric contraction begins.
  • At point “b”, the pressure in the left ventricle rises above the pressure in the aorta causing the aortic valve to open. Now begins phase 3 of the CC- ventricular systole. 70-90ml (80ml) of blood is ejected into the aorta. This is stroke volume.
  • At point “c” the pressure in the LV drops below that of the aorta and the aortic valve closes. The remaining volume/the end systolic volume in the LV is around 50 ml.
  • This allows you to work out the ejection fraction of the LV: 80/130=62%.
  • Now phase 4 of the CC begins-isovolumetric relaxation.
  • The pressure in the LV drops to below that of atrial pressure. Phase 4 ends and Phase 5 begins again.
  • Some pressure volume loop diagrams describe an additional line. This line represents the end systolic pressure volume relationship. (ESPVR). It is the maximal pressure that can develop by the left ventricle at any given LV volume.
  • This line becomes steeper/shifts left as inotropy/contraction increases and will flatten as inotropy/contraction decreases.

The post Basic Science in Clinical Context (BSCC) appeared first on LITFL.