Where’s that STAT karyotype?!!!

My awesome hematology colleague Dr Karen Dallas was here again – giving us a learn-on on a recent audit of routine Type and Screen testing in our ER’s

Background:

• Our biggest ER routinely sends a STAT Type & Screen to the Transfusion Medicine Lab [TML].
• These requests are often accompanied with a request for blood.
• Sometimes these tests are performed appropriately for emergent cases, but the TML saw an opportunity to study this [based on anecdotal experience that some of these requests may not be necessary.

Methods:

The TML undertook a 7 week chart review of patients who had a STAT T&S and blood products ordered. They uncovered a large source of wastage of pre-transfusion testing. The results would make anyone type and scream!

• 82% of our patients had a hemoglobin > 100.
  • 15% Hb between 70-100
  • 3% Hb < 70
• 90% didn't need any blood product
• even with being very lenient - 30% of the Type and Screen requests were deemed inappropriate

Many of our diagnostic tests do not change patient management. Furthermore they add cost, may confuse the diagnosis and might even force you to perform further tests that can result in harm [e.g. false positive exercise stress test - Patient gets angiogram - patient gets coronary artery dissection]

Discussion:

There are a couple of pearls we can take away from Karen’s plea.

1. Routine testing = thoughtless testing = waste of blood and money.

Those of you who know me know that I often rant about the wastefulness of routine blood panels. Don’t get me wrong. I do think that well-thought out protocols have value for example – at 4 am when I cannot think straight and may miss something. BUT in the middle of the day, coffee-in-hand:

a good clinician should be able to be selective about what he orders -  ANY test he chooses, he does so to either support or refute the pretest probability that a patient has “disease Y”.

2. Quality Improvement projects are valuable and necessary.

I encourage my residents to participate in QI because these projects are doable, supported with funds and often result in tangible benefits. If a project allows you to collaborate with other services to do what’s right – WIN! WIN! WIN!

Recommendations:

If you’re ER is like mine  you can improve on how it orders lab tests by:

Having a Gatekeeper – TML is now screening our orders and phoning the ER doc to clarify. This type of hand-holding is annoying, but may be necessary to change behavior in the short term.

Take a look at your protocols and see if there’s room to improve/reduce. For example, we order many T&S as part of a “Bleeding in Pregnancy” workup to look for the Rh status – We’re going to remove the test from the panel and call the lab to see if it’s on file first [because it usually is].

Educate each other on stewardship [my Earlier Post on Stewardship]

Reduce! Refuse and Reflect!

1. Reduce the amount of unnecessary testing in your ER. You can only gain from this.
2. Refuse to bow to requests for unnecessary tests [from patients and colleagues alike]
3. Reflect on your practice regularly and look for opportunities to change

 For your Interest:

Here’s a what the literature says about routine screening in the ER for:

1. ER patients in general [England]
2. ER patients in general 2 [Pakistan]
3. Psych patients
4. Patients with severe hypertension
5. Patients suspected of drug abuse
6. Patients with new onset seizure
7. Trauma patients (serum electrolytes)
8. Orthopedic patients
9. Adults and blood cultures
10. Kids and blood cultures
11. Pediatric Trauma patients
12. Adult Trauma patients
13. Adult trauma patients 2

The post Type and Scream STAT! Utility of ordering routine Blood Type and Screens in the ER appeared first on ERMentor.

I am a fan of Twitter. I use it to “keep my finger on the femoral pulse of Emergency medicine“. If you’re in medicine and you’re NOT on Twitter – you should be. I invite you to explore the people that I follow [link to my Twitter account] to see for yourself that it can be both clinically and non-clinically useful to you.

Thanks to one of my Tweeps [twitter peeps] Dr Sam Ko [Twitter link] I came across this talk on Emotional Intelligence by author Chade-Meng Tan. You can see the talk yourself here [link]. I have recently taken interest in mindfulness [check out additional resources at the end of this post]. I have also been trying to work on my emotional intelligence. So this talk struck me as a powerful blend of both. It seemed like a positive way to alter one’s approach in life – especially if you are in a position of leadership so I decided to share the basics of the philosophy below. [The pictures come from his presentation] I am sure Meng won’t mind as I just ordered the book. If you want to, you can order it also [from this link]. Okay – Let’s dive in!

Emotional Intelligence – What is it?

The following was taken from psychologist Kendra Cherry’s article [link here]: [Follow her on Twitter here]

• The concept evolved from the 1930′s when thinkers began to explore “the ability to get along with others”.
• The term “Emotional Intelligence” was coined by Wayne Payne in his doctoral dissertation in 1985.
• The term Emotional Quotient – EQ [as opposed to IQ] has been contentiously attributed a Mensa Magazine article that came about at the same time.
• In 1990 Peter Salovey and John Mayer publish their landmark article, “Emotional Intelligence,” in the journal Imagination, Cognition, and Personality, in which they outline the following components:

1. Perceiving Emotions

2. Reasoning with emotions

3. Understanding emotions

4. Managing emotions

It’s interesting that Meng – an Engineer – was reflecting on how to solve the problem of world peace when he gained this insight! He contends that the two ingredients to creating world peace are solving global poverty and creating a collective culture mindfulness. He figured that Bill Gates is already working on the former so he decided to work on the latter It was this quest that lead him to us today. He wrote a book and then spoke about it and his message is that:

Emotional Intelligence Can Be Learned in as little as 7 weeks

Chade-Meng describes this reciprocal relationship between our brain physiology and our behavior when speaking about emotions:

Emotions – just like pain – result from a nervous system response to a stimulus. Where pain comes from mechanical and chemical receptors that transmit signals to the brain  – which then forms the thought “OUCH!’ Perceived threats [real ones or ones that threaten us emotionally] set off a cascade of nerves and chemicals (particularly in the amygdala of the brain) and these create  feelings “FEAR” or “ANGER” or “SELF DEFENCE”.

Furthermore, Tan tells us that we often cannot ‘diagnose’ our feelings and tend to get overwhelmed by them. When we are flooded with emotions, the amygdala takes over and shuts down the rest of the cerebral cortex. This means that you literally cannot think and feel at the same time. Those of us that teach simulation know just how paralysing fear can be – most of us have learned to overcome fear of the sick patient through training, but we aren’t always so cool and collected when it comes to emotional interactions with others:

Imagine a recent awful interaction with a patient, colleague or consultant colleague. Wouldn’t it have been nice if you could have not let them get to you? Wouldn’t it have been better to have been able to keep a cool head and think your way (levelly) through the problem?

Meng provides us with a way to learn how to manage our emotions. He illustrates through the use of relevant research that what we pay attention to can lead to changes in our brain function. We can also learn to harness our EQ for personal growth and advancement and at the same time learn to control our emotions and keep a cool head. There’s probably more to it, but here’s a brief summary:

STEP 1: ATTENTION TRAINING

Creating a state of mind where you’re cool and and calm IS ACHIEVABLE: You have to learn how to pay attention in a particular way without distraction e.g:

Try focusing only on your breathing for 5 seconds without distraction. Breathe in … breath out … there! Mindfulness!

Creating a state of mindfulness on demand [and especially when the sh*t is hitting the fan] – simply takes practice.

It just takes practice?! I bet you’re thinking about Malcom Gladwell and saying “I don’t have no 10,000 hours!” Yes in truth when you look at functional MRI in monks – they can objectively down-regulate neuron activity in the amygdala with thousands of hours meditation:

 ”BUT EVEN IF YOU’RE NOT A MONK, IT ONLY TAKES 100 MINUTES OF MINDFULLNESS TRAINING TO SEE A MEASURABLE EFFECT” Chade-Meng Tan

So take that 5 second breath and see if you can stretch it out to 20 breaths or more over the next few weeks.

STEP 2: SELF- KNOWLEDGE AND SELF-MASTERY

Anyone ever tried to learn how to flex their pec muscles [or raise only one eyebrow]? What about when you learned to whistle? I think of mindfulness like learning to twitch an isolated muscle – probably will only take a couple of weeks of practice before you start to get the hang of it. Once you do, practising it will pay off in the following ways:

•  Mindfulness makes the mind sharp. Through conscious attention, we can become in-tune with our body – including our emotions. With practice  we can perceive the smallest of changes.
• The increased resolution allows you to even perceive emotions as they arise. This give you the power to control them rather than the other way around. So that feeling of “I wish I wouldn’t let so-and-so get to me” becomes a willful choice to not let it happen [because you perceived your emotional response to the situation early and chose not to react ... makes sense?]
• You begin to see yourself more objectively, empathetically and reflexively. You thus gain insights into your deepest values, strengths and assets. This means that you are in a better position to seek opportunities that may change your life.

ALIGNING YOURSELF WITH or SEEKING OUT OPPORTUNITIES THAT REFLECT your INNER VALUES AND ASSETS is how you achieve meaningful change in your life.

One big thing I learned from the talk was that:

We need to understand that our emotions are NOT us, yet we are taught to express our feelings as though they are. Example “I am sad” “I am angry”

• The above statements are existential ones. The emotion becomes you – even though there is no real basis for this. [remember your emotions are simply a neurochemical response to a stimulus right?]
• Instead – focus on a more experiential statement. “I am experiencing sadness” – so [just as if you were experiencing pain] you can chose to do something about it like take an analgesic – or ignore it.

STEP 3: CREATING USEFUL MENTAL HABITS

Meng finished his talk by illustrating that practising kindness and empathy leads to personal success – especially if you are a leader.

• Practising Kindness:

The simple act of thinking that you actually want your audience/staff to be happy is not only good for you [because you're rehearsing good emotions], but it also changes your non-verbal communication. People perceive this and respond to it positively leading to your success. You know – maybe it’s NOT such a bad thing to want to win a “popularity contest” :

• Practising empathy:

Similarly, the act of thinking of other people as “someone just like me” has both selfish and altruistic benefits. On the personal level,by seeing yourself as just like others -  you can develop a more grounded approach to life. The benefits are that you are better able to manage your expectations. [Ever heard that the key to happiness is to manage your expectations?]

Furthermore good interpersonal relationships develop into more meaningful ones and rocky relationships may actually find some middle ground – making your life in general less stressful. The altruistic effect is that you’re creating goodwill among others – perhaps making their lives less stressful. There is not only a ripple effect [altruistic] , but also a positive feedback mechanism as goodwill begets good feelings [selfish] – So get out there and be kind and empathetic because ultimately you benefit

Hopefully I have shared something useful to you and maybe even inspired a couple of you to think differently. I am sure that there’s way more to it than I have summarised and am intrigued to get the book and read it [Meng - if you read this - be kind ]

MY HOMEWORK

1. Practise mindfulness

2. Practise random intention of wanting others to be happy

3. Reap the rewards

 ADDITIONAL RESOURCES:

Ian Miller of The ImpactedNurse recently posted stuff on Mindfullness check it out here [link]

Robert Cooney did a 2-part blog on Mindfulness here are the links: Part 1 and Part 2

Emergency Medicine Tutorials recently also posted on this [link]

The post EQ and how it can make you a Selfish Altruist appeared first on ERMentor.

from http://www.fitsnews.com

One of my colleagues  – Dr Van De Kamp -  gave us a talk on how we can improve on our evaluations of learners. [I have taken her talk and added some of my own reflections/literature].Duff et al in 2003 illustrate:

“Giving the benefit of the doubt has consequences for future mentors, students and, may ultimately, have professional consequences”

This talk was quite topical as a recent publication in the New York Times [read here] highlighted how we as a medical community seem to continually pass problem learners [nursing also seems to be afflicted with the same blight]. As one colleague recently remarked:

“The only thing harder than getting into medical school is getting out!”

Schaana collates all the learner evaluations and lamented about what she observed as “leniency bias” on the evaluations …

The vast majority of evaluation forms evaluate learners as “exceeding expectations” when, in reality, it’s IMPOSSIBLE for ALL these learners to be excellent!

Why do we do this? What is so hard about grading students?

• Our fellow high school, undergraduate and postgraduate educators don’t seem to have a problem with failing students!
• As many as 30% PhD candidates fail.
• Interestingly we don’t seem to have the same problem with evaluating International Medical Grads [article]

Why our feedback fails:

There is no one reason why faculty aren’t very good at evaluation. Most of the factors that I have listed below aren’t entirely exclusive of each other.

Why Leniency Bias?

Woodward et al [Pubmed Link] suggest that there exists a leniency bias whereby evaluators inflate the ratings of students. Bass [in an ancient article - link] suggests 8 reasons why we’re so lenient [I have highlighted the ones that seem valid to me]

1. Rating a learner poorly [who is under your jurisdiction] may reflect on our own unworthiness.
2. Assuming that the real under-performers should have failed already.
3. Fear of interpersonal discord from giving a poor evaluation.
4. Trying to pass a learner on in order to influence them in the future.
5. Projecting.
6. Feel the need to approve of others as a way of feeling self-approval.
7. Operating on the basis that “he who associates with me is meritorious therefore I too am meritorious”
8. We exist in a culture of approval.

There’s little doubt that leniency bias exists and it’s roots may be multifactorial and difficult to get at. One of the tenets of curing a disease is to identify it.

The Feedback Form May be Flawed

• Thompson et al in 1990 [PubMed Link] suggested that the problem might be with the actual evaluation forms. In the last three years, we’ve modified ours twice.
• However, Bandiera and Lendrum show that, even when we create a better daily evaluation card, leniency bias still creeps in [Link].

Despite these drawbacks, one should never be afraid of modifying and re-modifying the evaluation tool – because, in truth, the data on the evaluation form needs to reflect the outcome that you are trying to assess.

 The Quality and Timing of the Evaluation

• We seldom take the time to actually observe a history being taken, physical exam or discharge instructions being stated [infact we may inadvertently hijack the latter].
• In the ER evaluations usually occur at the end of a busy shift when one is rushing to go pick up the kids – this also sets us up to fail. One has to set aside time for a proper evaluation.
• Furthermore, we know that instructor presence positively influences student evaluations of the instructor – so does this mean that if the learner is sitting in front of you – you’re more likely to be lenient? I think so.

Having a learner on shift comes with responsibility. You have an aprrentice that needs observation, guidance and feedback. You have to change the way you approach the shift. [Refer to my previous blogs about teaching in a busy ED and assessing the learner] I cannot stress enough the importance of direct observation.

The “Halo Effect”

• Thompson et al also refer to a “halo effect” – allowing the general perception of the learner to bias the evaluation of specific competencies. i.e. “I like Bob – so I am more likely to overlook his below-average suturing skills”

I would argue – if you really like Bob – for his own benefit you need to highlight his inadequacies.

Lack of Self-Efficacy:

• Most EM docs are just that – EM docs! That is many perceive that they are clinicians and not educators. This lack of self-belief [in ones ability to effectively evaluate] leads to leniency.

Here in Saskatoon we have tried to address this by having Faculty Development [where this topic was discussed].

“Isolated event” hypothesis.

• Many of us only get one shift with that specific learner. We therefore may tend to discount our ability to grade a learner objectively – after all – what if the student is just having a bad day?

Enter the Daily Encounter Card. We need to stress to our faculty that they are providing formative feedback for that shift only. Faculty need to feel empowered to “be the bad guy” and fail the student on a specific role … or even fail that particular shift.

Additionally scheduling faculty and learner together for a series of shifts may help [only if the faculty member is good at identifying inadequacies and commenting on them]

Lack of support, engagement and coordination.

• Most EM clinicians are “community faculty” they don’t have an office. They don’t know the who’s-who in the Undergrad office, and most of them have never met the Dean. They work in isolation without much engagement from the college.
• There may also be a perception that they are not ultimately responsible for this student.

These are clear disincentives to take the time and effort to properly evaluate learners rather than give a cursory shot at it. There is a dire need for a coordinated and multi-disciplinary approach to all learners that includes 360 feedback, more observation, more emphasis on the “soft skills” and perhaps – prescribing more failure.

“Big Deal” Hypothesis.

• Okay there’s no such label. But in my experience, evaluators tend to be more lenient when they perceive that their negative evaluation may have negative consequences.We know from the literature that feedback for the purposes of academic promotion tends to be more lenient.
• Related to this is the huge investment that has already been made and needs to be made if the learner were to be held back. I think that this is at the heart of what happens when we pass on problem learners. I have heard – it takes an inordinate amount of effort to remediate and potentially fail a learner rather than minimise some inadequacies – especially if they are “soft skills”.

Collectively as faculty we need to take ownership and almost seek opportunities to critique [or even fail a leaner] – It’s like screening for sepsis … you won’t find it unless you look for it.

We shouldn’t feel like its a huge challenge because it’s not. The conscientious learner will actually thank you for it. The rewards of turning a learner around is well worth it:)

Humans are flawed

• We’re not perfect. Far from it, we’re in fact set up to make biased decisions. We are thus predisposed to make flawed evaluations.

The key is to recognise when you’re making judgements about the learners and when you may not be fit to evaluate objectively [you're stressed and angry].

HOMEWORK

I am interested in learning more from your comments. In the meantime my short-term goals are to:

Give Specific Feedback about characteristics observed during that shift:

• Download a picture of the CANMEDs Roles. Use them as a guide!
• Alternatively use Pangoro’s RIME Criteria [Link]

Give More Tough Love

REFERENCES:

BERNARD M. BASS. Reducing Leniency in Merit Ratings. Personnel Psychology. Volume 9, Issue 3, September 1956, Pages: 359–369,

Howard K. Wachtel (1998): Student Evaluation of College Teaching Effectiveness: a brief review, Assessment & Evaluation in Higher Education, 23:2, 191-212

This is a great article for would-be edumacators:

Reed G. Williams , Debra A. Klamen & William C. McGaghie (2003): SPECIAL ARTICLE: Cognitive, Social and Environmental Sources of Bias in Clinical Performance Ratings, Teaching and Learning in Medicine: An International Journal, 15:4, 270-292

The post How Can EM Faculty Be Better Evaluators? appeared first on ERMentor.

from http://www.aerocareinternational.com

This is the first in a series of talks that I attended at a local faculty development day. The speakers agreed to have me share their wisdom with you – enjoy! The following is an exerpt from my brilliant colleague Dr. Rob Woods’ talk on using the 5 C’s of consultation.

Bad consults are bad for patients.

Consulting colleagues is a critical skill in Emergency Medicine. The success of a good consultation is more than simply getting the consultant to come see the patient. Rather – it’s getting the best out of your consultant so that ultimately the patient benefits. Poor consultations not only make you look like a dork. They will have downstream effects on how  well your consultations are received for the rest of that day and in the future.  Additionally they WILL impact how you and your colleagues are perceived by others [see my blog on Branding Yourself]. Worse – they CAN lead to bad patient care as you may not be taken very seriously.

Things that set you up for a bad consult

1. You’re not ready to deliver your question – You are trying to get the consultant to see things the way you see them. You need all the details at hand. Anticipate questions/be your own devil’s advocate.
2. You do not have a clear question. Getting the best out of people means letting them know what you want.
3. No previous contact with the consultant [either you or consultant may be new]. It’s important to introduce yourself. It’s also important to seek opportunities to network with the colleagues you consult most.
4. The system is overloaded. The reality today is all other services are also overwhelmed. No-one wants to hear from the ER – even more reason to do things right.
5. Known-to-be difficult consultant. Nothing you can do about this except owning how you interact with this person.
6. Lack of skills – Let’s face it. We don’t get a lot of instruction on the so-called “soft skills” in medicine.

Chad Kessler’s 5-C Model

Dr Kessler has studied and published his model for communicating with consultants [Pubmed Link]. Here’s the Coles Notes:

Contact

This is the first part where the consulting and consultant physicians are introduced. The goal is to build a relationship. The way to do this is:

• State your  name
• State your rank and service
• Identify your supervising attending
• Get the name of consultant physician [crucial for relationship AND ALSO for documentation]

Communicate

In this phase, provide  a concise story and ask focused questions.

• Speak clearly and methodically [slow down at night - remember you just woke the guy up]
• Give an accurate account of the details

Core Question

You MUST have a specific question or request of the consultant. Decide on reasonable time frame for consultation.

Collaboration

Be open to – and even solicit alterations in management from the consultant.

• Remember – you aren’t always right some back and forth is normal and appropriate.

Closing the  Loop

Ensure that both parties are on the same page regarding the plan and maintain proper communication about any changes in the patient’s status.

• Repeat this plan back to the consultant
• Write it down

Further Reading

A fellow blogger also blogged about this – please take time to round out your learning by reading her post [click here]. You probably should also follow her on Twitter @LWestafer

The post Requesting Consultations using Kessler’s 5-Cs appeared first on ERMentor.

from: http://blog.openviewpartners.com

Psychiatry presentations comprise about 3-4% of total presentations, but account for way more work.

It’s a common mis-perception that psych patients require a one-hour intensive interview in order to ascertain what they need. Not true.

We got an inservice from one of our psychiatry faculty today. He allowed me to share his pearls on the most important parts of a history that can be done in 15 minutes:

The Nuts and Bolts of Psychiatric Emergency Interviewing- Dr GENE MARCOUX

Most important pearl:

You can run but you can’t hide from Psychiatry.  You may as well get good at it.

Diagnostics:

• The Wise Men Questions:  ask Who, What, Why & When
• In or Out? Try and ascertain whether the patient is going to need admission [e.g. SADPERSON score >8-9]
• Function trumps Symptoms in Psychiatric Evaluations. If they’re functioning – don’t need to come in.
• Psychosis does not necessitate a review.  Poor choices as a result do.
• Mania, Intoxication and Antisocial PD (in that order) predict violence.
• “Can you keep yourself safe?”  Best single question to evaluate suicidal risk.
• Is there mental illness in your family? Single best FHx question to ask.

Therapeutics:

• What meds are they on and their family on?  Best question to determine Therapeutics in drug naive pts.
• Increasing current meds, best stop gap strategy in ER vs. switching or starting.
• Olanzapine/Seroquel tabs: best/safest meds to send home in small quantities.
• BPAD: toughest Psychiatric Illness to treat, poorest meds, poorest outcomes.
• Consultants are generally really receptive to phone calls in order to come up with a plan.
• Antidepressants: Poorest Psychiatric Meds.
• Antipsychotics: Best Psychiatric Meds.

Further reading:

• Suicide risk – good stuff from ERCAST [click here]
• For Medical Students: A Neat [and concise] article by Bill Young U of Kentucky on Suicide Risk [click here]

The post Pearls of Evaluating Psych Patients in the ER appeared first on ERMentor.

Recently read this interesting Infographic from The Daily Infographic [Link]. It deals with water consumption:

I found this infographic interesting because I often think about water sustainability. I am not an environmentalist by any means. In fact I am not even CLOSE!  … But one of my resolutions this year is to be just a little more responsible in my daily life. Canada has a lot of fresh water [Saskatchewan has 100,000 lakes] it’s one of our most precious [yet oft wasted] resources. They even made a fictional miniseries about a Canadian Prime Minister selling out our water to the US [Link to IMDB - H2O]

I am getting off topic. The Infographic stimulated an internet search for physician environmentalists. I learned that there are a number of organisations in Canada and in the US that are run primarily by docs who are passionate about social responsibility. It got me thinking that perhaps involvement in an ‘environmental’ organisation may be a way to carve out a non-clinical niche for yourself.

Several of the groups below share common goals of nuclear restraint, antiwar and responsibility around climate and water. Reading their material made me feel a bit “doomsdayish”, but then I thought – we’re physicians! One of our roles is to be health advocates!

Fact:  nuclear accidents and war have caused clear, significant and  indisputable misery across the globe.

Maybe it’s not such a bad thing for more of us to be involved. Unlike other EM niches – you probably won’t get remunerated monetarily, but I am wondering maybe if your niche shouldn’t be another paying job …  I’ll leave that up to you

Organisations for the Socially Responsible ER Doc:

In case you’ve never heard of them – MSF/Doctors Without Borders  [Link]

The Canadian Association of Physicians for the Environment [Link]

The Canadian Pugwash Group [Link]

For my American friends – Physicians for Social Responsibility [Link]

How to be more Water responsible at Home

Environment Canada shows you some tips [Link]

My Homework:

1) Shorter showers!

2) Donate

3) Learn more

The post Social Responsibility as an EM Niche? appeared first on ERMentor.

from www.maninstitute.com

After having seen several cases I thought that this was important enough to share. [Can't believe that this hasn't been published in a major journal]. Below I describe the pathophysiology and teleology and then finish up with two cases from recent memory.

Introduction:

“did you see grandpa pick up that keg of beer?”
…”Yeah he has sick old man strength”

Ever heard of an Old Timer displaying an inordinate amount of strength for a man his size/age? [e.g. ... opening the jam jar that you couldn't ... or loosening that lug-nut on your tire (that you couldn't) ...]. These superhuman feats are what we call Old Man Strength Syndrome [OMSS].

The Urban Dictionary [link] provides the following definitions:

“crazy, insane strength you gain when become an old man”

“usually acquired at the age of 40″

“…can be used to lift copious amounts of lumber, furniture beat your sons at arm wrestling”

Anecdotally I have found that OMSS usually begins later in life and includes a symptom complex of ‘wiry’ upper body strength, out-of-the-box problem-solving that usually includes the use of  only bare hands. Old timers displaying OMSS also more often than not show imperviousness to harsh environments and seem to share the same oral traditions that begin with the saying “back in my day …” [This is a fascinating cross-cultural phenomenon]

Pathophysiology and teleological purpose to OMSS:

Like many conditions, we are only beginning to understand the physiology.  There are several competing hypotheses and they may not be mutually exclusive.

“Harsh Times” Hypothesis:

Simply put … the older you are, the harsher the environment of your formative years appears to have been. How this conveys super-human strength is poorly understood however. There may be some correlation to functional strength required to walk long distances to school [uphill both ways].

We know for certain that if the person is a war veteran – this alone is a strong predictor of OMSS. Authors B & K MCKay illustrate [link to article] that the functional fitness expected of WW2 GI’s became a lost art until recently when it was discovered that modern day soldiers cannot pass the historical fitness tests. This is leading to an overhaul of modern fitness test to  a more “cross-fit” type test.

“Basically, Grandpa was doing Cross-Fit before it was cool” [ArtofManliness. com]

Hybrid Strength Hypothesis:

Author M Westerdal [link] explains the difference between  “…being gym strong versus real-life strong”. He uses the case report of himself [a high-school football star] and his father [who never worked out a day in his life, but did a lot of manual labor] and describes a day when they had to remove heavy rocks from their yard. Westerdal’s father displayed OMSS by effortlessly lifting the rocks!

“This Old Man basically kicked my A** with Real World Strength!” [http://leehayward.com]

Westerdal goes onto explain that years manual labor, building things around the house and having to fix things himself built Hybrid Type III Muscle in his dad. This muscle allows one to perform extraordinary feats time and time again! This is in stark contrast to “gym-strength” – which builds Type I and II muscle by individually isolating muscles.

The movie Rocky IV highlights the superiority of real-world strength versus gym strength – if you haven’t seen it you should.

Mind over Muscle Hypothesis:

Basically Old Geezers believe that they can. Author JD Johannes explains that this self-belief allows geezers to  harness their Maximal force [link]. Combined with years of refined use this mental fortitude results in OMSS.

Teleology of OMSS:

The authors of The Manstitute.com suggest that OMSS allows men to get manlier with age and serves the purpose of raising male progeny. There also appears to be a positive feedback mechanism:

“Your Old Man Strength begins to kick in from the moment you start teaching your son to be a man. The manlier you make your son, the manlier you become. This is the benefit you get from showing a brand new man the ropes.”

Case Review:

Case 1

Perhaps the most famous display of OMSS ever was that displayed by Mr. Miyagi from the blockbuster hits Karate Kid 1 and 2 . Check out this scene from KK1 where he single-handedly takes down some bullies [Link]

Case 2

Bob Barker might look like someone you could take in a fight, but make no mistake! You could end up like this victim who underestimated the powers of OMSS [Link]

 Putting Knowledge into Practice:

1) You may want to validate the existence of OMSS by challenging one of your elders to an arm wrestle. I advise caution as you will certainly lose and trying to up the ante may result in a whuppin’

2) Old geezers demand respect. Give it to them – they’ve earned it through harsh times.

3) If you’re male, you too may cultivate OMSS in yourself by performing tasks that require real-life strength.

from http://artofmanliness.com/

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Came across this app after talking to the bartender at my local haunt. It’s called DIPTIC [click here for website]. The app allows one to put together 3 or more pictures to “tell a story”. The app costs $0.99

I am still chewing this over, but I think one educational application of this would be to create what I call “learning shots”. Learning shots are small snippets of learning that can be pulled up at a moments notice [like on the fly teaching in the ER].

You can create them yourself using PowerPoint . I have a bunch of 1 to 2 page PowerPoint presentations with bullet points explaining various concepts – like the one below on Salicylate toxicity:

Michelle Lin who writes Academic Life in EM – also has her Paucis Verbis cards which I use regularly. [Click here for a link to her blog]

Below I have included a “Diptic” that I created to conceptualise Meckel’s Diverticulum. Comments?

images from pediatricsurgerymd.org and wikipedia.

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I thought I made it clear in my email … ONE INDENT NOT TWO!!!

I was reflecting on a recent conversation with my sister in law about someone who sent a farewell email to her entire company. We debated the appropriateness of this. It made me think of stupid things that I have done with email. I thought that I’d share …

Ever hit “reply all” by accident and sent a message disparaging someone? √ CHECK – This goes down as one of the most unprofessional and regretful things I have done. The back-peddling and crow-eating didn’t compare to the damage this did to my reputation. For more on Branding yourself appropriately click on this link

Ever tried to be funny/sarcastic using email and have your words received the wrong way? √ CHECK – I once sent an email to my Medical Classmates haranguing them for RSVPing to an event and bailing – leaving +++ wasted food. No biggie – the food went to the ER nurses lounge … so I was trying to be witty and sarcastic, but nevertheless the outcome was disastrous! Unlike words spoken, no one can see your smile or your expressions behind the words in an email. Sure emoticons exist – but they just don’t cut it.

Ever sent an angry email that you wish you could have clawed back? √ CHECK – We’ve all had those work issues that make us want to LOSE IT! For sure, getting riled up shows your passion, but it also makes you look emotionally unstable  … Before you blast off online Try these three simple rules 1) Hit “save” … sleep on it and come back to it later. 2) Before hitting “send” run these emails by your spouse/a friend/colleague. 3) Consider NOT EVEN sending a reply at all [ especially if it won't really achieve anything other than allow you to vent]. This way you come off sounding measured, fair and mature despite being vexed.

There’s one oldie-but-goodie principle that should guide all your online interactions:

Like grandma always said – If you’ve got nothing good to say, don’t say anything at all.

Those that know me often hear me joke that the online version of me is a better person than the real-life me! What I mean by this is … I try to never flame or blame online. My guiding thought is “Don’t put anything negative out there” – this way you ensure that you’re always saying the right thing.

One last mistake I still find myself doing is:

Ever tried to resolve an issue using back and forth emails like ten times? [or texting back and forth for that matter?] √ CHECK – USE THE G-DAMN PHONE FOR WHAT IT WAS INTENDED!!! way more efficient

For more Commandments on using Email Properly click on this blog post link from Work-Life Coach Ann Mehl.

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