zaWiRowania

Zawirowania

Kilka lat temu zdarzyła mi się dość ciekawa wycieczka ponad Wielką Wodą na pokładzie C-17. Znawcy od razu wiedzą, iż chodzi o yankeski samolot transportowy używany przez siły zbrojne tego kraju. Była to moja pierwsza przygoda z tego typu środkiem transportu. Na pokładzie, poza załogą i garstką moich współpasażerów, znajdowały się szczątki innego roztrzaskanego samolotu bojowego. Moja mina musiała wzbudzić duże rozbawienie wśród stałych bywalców tychże samolotów, bo już po chwili rozmową rozpraszał mnie podoficer z U.S. Marine Recon.  Rambo i dżentelmen w jednej osobie. Uwagę zwracał mocno zużyty ale nienagannie odprasowany mundur, pocerowany plecak oraz jego czworonożny towarzysz rasy belgijski pies pasterski, który prezentował się jak na wystawie. Zdziwiła mnie skromność jego wyposażenia, gdyż  jakby nie było przynależał do elitarnej jednostki wojskowej. Z głupiej ciekawości zapytałam o przyczynę takiego stanu rzeczy, a on odparł mi coś na kształt: „jak się nie ma co się lubi, to się lubi co się ma„.

Ta przygoda sprzed 7 lat przypomniała mi się przy okazji artykułu „Komandos i sanitariuszka„. Wzruszająca historia legendarnej sanitariuszki Armii Krajowej – Hanki „Sławki” Jędrzejewskiej, oraz operatora/ratownika pola walki z Jednostki Wojskowej Komandosów przedstawionego pod pseudonimem Wir. Wir jest laureatem tegorocznych Buzdyganów. Swoją prestiżową nagrodę przekazał Pani Halince w podziękowaniu za wzór i inspirację do pracy…

Gdzies kiedys terazZaraz zaraz… Zastanówmy się przez chwilę nad tą dedykacją… Wygląda na to, że w kategorii inspiracji nawet w XXI wieku determinacja wygrywa z zasobnością? „Mind over matter” jak to mawiają anglojęzyczni?

Prawda jest taka, iż wielu z nas przywykło do narzekania i krytykowania. Nigdy nie jest nam wystaczająco dobrze  i bez przerwy pożądamy zmian. Sprzęt zbyt lichy, płaca za mała, ustawa do kitu… W moim przypadku można by jeszcze dorzucić nieustające wędrówki po świecie…

Zabrzmi to pewnie zbyt banalnie… Z przykrością stwierdzam, iż miejsc idealnych nie ma. W każdym kraju, niezależnie od jego bogactwa, jest niesamowicie dużo głupoty. Wszędzie znajdzie się bezmiar bezmyślnych rozwiązań… Nie zapominajmy, że nawet najlepsze pomysły sąsiada tudzież dalekiego ziomka, to i tak tylko „pokazówka” a nie odzwierciedlenie codzienności czy też większości.

Nie ma nic złego w dążeniu do poprawy, ale pamiętajmy iż nie każda zmiana jest ulepszeniem. Krytyczne podejście do stanu rzeczy jest jak najbardziej pożądane, pod warunkiem iż przedstawia się osiągalne w danej chwili rozwiązania. Od narzekania nikomu się jeszcze nie polepszyło!!! Pozytywne zaWIRowania to domena ekspertów i pasjonatów.

10000

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10000… You might wonder why on earth would I pick a number as a title of my blogpost… The answer is: to make you wonder ;-) and to mark a major milestone! Unfortunately not my own, but one that I would hope to reach some day.

Can you imagine having physically trained 10000 emergency physicians in bedside ultrasonography? Not only through a textbook, or a #FOAMed resource of some sort, but via actual classroom interaction! Well, I just got off the phone with Steve Socransky. He and his colleague, Dr. Ray Wiss, can certainly claim this kind of an achievement. Their initiatives led to the creation of Canada’s National ED Ultrasound Course (a.k.a the EDE Course and the EDE 2 Course). Check it out & make sure to follow the EDE Blog!

Reflecting on my conversation with Steve I must say that a good basic ultrasound course is absolutely priceless! Learning how to scan and being able to generate clinically useful images is quite an art indeed… Having obtained more than 2000 sono studies (stopped counting at 2000 a few months ago), I have to admit that mastery of bedside ultrasonography is a life-long commitment rather than a matter of a few scans. While the equipment is getting smaller and more capable of generating gorgeous images, our patients tend to get bigger and less echogenic. Every single scan should be treated as a valuable and humbling exercise in perfection. Humility and healthy self-criticism tend to save lives. Boastful overconfidence has quite the opposite effect.

#EuSEM14 Let’s meet in Amsterdam!

#EuSEM14

I can’t believe it’s already March 2014! Time is flying as always… And soon enough I’ll be flying over to the Netherlands for the big event of the European Society of Emergency Medicine (EuSEM). Thrilled to meet all my fellow EM enthusiasts in Europe. September 27th – October 1st Amsterdam is the place to be.

EGLS

The conference itself starts on September 28th, but you can’t afford missing the ULTRASOUND COURSES taught by EGLS guys. Jean-François and Max will surely teach you quite a few new tricks. Sessions are foreseen for the sono-intrigued beginners and sono-obsessed advanced users. I’ll be there – role yet to be determined. At the very least I’ll help Ingvar ”babysit” ;-) the JF-Max duo. You just never know with the Canadians!

Crispijn van den Brand, current President of the Netherlands Society of Emergency Physicians (NSEP) and the organizing committee surely have quite a treat for you. It’s Amsterdam after all! So don’t hesitate and book your trip! No worries, whatever happens in Amsterdam, stays in Amsterdam… ;-)

Let’s meet in Amsterdam for #EuSEM14!!!

P.S. You don’t have to miss #ACEP14 in Chicago… I’m just saying – in case you planned on using it as an excuse!

Echos from the lion’s den

Echos from the lion's den 2Over the past 3 weeks I’ve had the honor, the privilege and the … to hang out with the „big boys” in the lion’s den (a.k.a. the echocardiography lab). It’s been a lot of fun and quite a learning experience. I’ve discovered a fair number of their „dirty secrets” while playing the „eyeballing game” with the guys. Here are the rules:

Eyeball the Heart game 2

It is obviously not my goal to ridicule the art and the skill of an experienced cardiologist. Nevertheless the interaction prompted some questions which are likely to remain unanswered. To be honest I was fairly surprised by the level of subjectiveness governing the echocardiographic interpretation. A little more or a little less is just a matter of a slightly different caliper placement. Hence I am asking… Why do we care about the absolute numbers  if they’re a product of an estimation? Why do we allow those digits to guide important clinical decisions (e.g. AICD placement) if they’re a matter of comparative assessments and relative impressions? Furthermore, why would one argue against the value of a bedside echocardiographic evaluation by a trained non-cardiologist if that is enhanced with real-time clinical clues and patient’s historical data?

JASE-gateI am not sure if it’s money, pride, ego or all of the above, that drive hostility towards point-of-care echo evaluations by emergency physicians or critical care providers, as an example. There are no logical arguments in this debate and statements such as recent JASE gate (a.k.a. Focused Cardiac Ultrasound recommendations from the American Society of Echocardiography) are inconsistent with patient advocacy. Countless lives have been saved and even more outcomes have been improved thanks to bedside echocardiography. Let’s quit the dispute and focus on mutual education. Beyond any shadow of doubt we can learn a lot from our cardiology colleagues, while we can certainly teach them a trick or two…

Speaking of echo education. Below a few of the million interesting echo resources:

  1. Newest first! My most recent discovery is a fantastic article from January 2014 issue of Critical Care Clinics. Drs. Perera, Lobo, Willims and Gharahbaghian provide you with an exhaustive point-of-care echo review.
  2. Introduction to Bedside Ultrasound by Matt & Mike in 2 digital volumes.
  3. Intro to Bedside Echo by Joe Minardipart 1 and part 2. Created for medical students – great for anyone!
  4. Yale Echo Atlas
  5. Nice iASE app for the big boys/girls. Advanced echo recommendations, summaries and calculators from the ASE (American Society of Echocardiography).

To TEST or NOT to test?

To test or not to test.001

I am just going through my PILE OF GUILT (read: stack of EM literature) that tends to accumulate over time… At the very least I try to browse through the journals and magazines as they trickle or pour in, but sadly enough I end up playing a catch-up game.

The August 2013 issue of the Annals of Emergency Medicine ended up waiting for its review until December. Such a 4-month delay is nothing to be proud of :-(. Especially because of this excellent editorial by Dr. Steven Green on clinical decision rules. He describes common pitfalls and important caveats concerning these clinical tools. They are omnipresent in our daily practice and we tend to apply them as a sort of bandaid or anti-lawsuit remedy. The problem is that quite a few of the rules add little or nothing to our sound judgement (read: GESTALT). They are far from being the Holy Grail of emergency medicine, so before you choose a given rule and potentially cause more harm than benefit to your patients, consider the following factors (after Dr. Green):

  1. Relevance of clinical question – simply don’t bother with rules that answer trivial or unimportant questions.
  2. Derivation – best rules meet rigorous derivation standards.
  3. External validation – crappy decision rules perform great in the derivation sample but fail if applied to a new patient sample.
  4. 1-way versus 2-way application – most rules are designed as 1-way tools, and lead to negative consequences if applied in a 2-way fashion. Let’s take PERC (Pulmonary Embolism Rule-out Criteria) as an example. You are supposed to forego further testing if the patient is „PERC negative”. It is not meant to indicate the need for a PE evaluation if patient is „PERC positive”. If applied in 2-way fashion this rule would lead to increased testing and potential harm.
  5. Implication for current practice – ask yourself if the rule improves your clinical gestalt. In a multitude of medical conditions gut feeling seems to perform better, e.g. pulmonary embolism.
  6. Applicability to your patient population – certain rules do not factor in modern practice patterns such as use of bedside ultrasonography, which honestly makes them redundant and obsolete to begin with.
  7. Ease of use – who on earth has the capacity to remember all those multi-step rules? Availability of automated calculators and/or drop-down charting add-ons certainly increases applicability.

The bottom line is – majority of the rules are more of a double-edge sword than a protective shield. It is unwise to apply them in an automated fashion. Once you’ve built your clinical judgement it is often superior to any rules. Nevertheless, these tools probably help to unwrap your gestalt from its immature cocoon.