Extreme acidosis – how low can you go?

How low a pH can the human body handle? How bad is acidosis in cardiac arrest? Is there any point attempting to resuscitate a cardiac arrest patient with a pH of 6.8?

In this lecture from #SWEETs17, Jonathan Ilicki presents a poem covering cardiac arrest physiology, acidosis and the extreme boundaries of the human body. Discover what acidosis does to the human body and how low we can go!

Video

 

Podcast

Slides


Slides as pdf.

About Jonathan

  • Emergency Medicine Resident, Clinical Innovation Fellow. EM resident at Karolinska, Stockholm. Special interest in arrestology and EBM. Find him on linkedin. Email: j dot ilicki at gmail.
  • More content on his youtube channel
  • He promises to be on twitter soon…

 Credits

More from SWEETs17

Stay tuned for more talks from SWEETs17 here on scanFOAM. Also, make sure to follow the SWEETs team on twitter.

References

1
Gaskell WH. On the Tonicity of the Heart and Blood Vessels. The Journal of physiology 1880; 3: 48–92.16. [PubMed]
2
LEDINGHAM IM, NORMAN JN. Acid-base studies in experimental circulatory arrest. Lancet (London, England) 1962; 2: 967–9. [PubMed]
3
Edmonds-Seal J. Acid-base studies after cardiac arrest. A report on 64 cases. Acta anaesthesiologica Scandinavica Supplementum 1966; 23: 235–41. [PubMed]
4
Soler NG, Bennett MA, Fitzgerald MG, Malins JM. Successful resuscitation in diabetic ketoacidosis: a strong case for the use of bicarbonate. Postgraduate medical journal 1974; 50: 465–8. [PubMed]
5
Orringer CE, Eustace JC, Wunsch CD, Gardner LB. Natural history of lactic acidosis after grand-mal seizures. A model for the study of an anion-gap acidosis not associated with hyperkalemia. The New England journal of medicine 1977; 297: 796–9. [PubMed]
6
Weil MH, Rackow EC, Trevino R, et al. Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. The New England journal of medicine 1986; 315: 1616–8. [PubMed]
7
Bozzuto TM. Severe metabolic acidosis secondary to exertional hyperlactemia. The American journal of emergency medicine 1988; 6: 134–6. [PubMed]
8
Martin GB, Nowak RM, Cisek JE, Carden DL, Tomlanovich MC. Hyperkalemia during human cardiopulmonary resuscitation: incidence and ramifications. The Journal of emergency medicine 1989; 7: 109–13. [PubMed]
9
Seguchi M, Jarmakani JM. Effect of respiratory acidosis on hypoxic newborn myocardium. Journal of molecular and cellular cardiology 1989; 21: 927–34. [PubMed]
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Shapiro JI. Functional and metabolic responses of isolated hearts to acidosis: effects of sodium bicarbonate and Carbicarb. The American journal of physiology 1990; 258: H1835-9. [PubMed]
11
Orchard CH, Cingolani HE. Acidosis and arrhythmias in cardiac muscle. Cardiovascular research 1994; 28: 1312–9. [PubMed]
12
Opdahl H. Survival put to the acid test: extreme arterial blood acidosis (pH 6.33) after near drowning. Critical care medicine 1997; 25: 1431–6. [PubMed]
13
Refsum HE, Opdahl H, Leraand S. Effect of extreme metabolic acidosis on oxygen delivery capacity of the blood–an in vitro investigation of changes in the oxyhemoglobin dissociation curve in blood with pH values of approximately 6.30. Critical care medicine 1997; 25: 1497–501. [PubMed]
14
Warner OJ, Palazzo FF, Ward ME, Waldmann C. Survival after cardiac arrest with a pH 6.6. Resuscitation 2001; 49: 213–5. [PubMed]
15
Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation 2004; 109: 1960–5. [PubMed]
16
Makino J, Uchino S, Morimatsu H, Bellomo R. A quantitative analysis of the acidosis of cardiac arrest: a prospective observational study. Critical care (London, England) 2005; 9: R357-62. [PubMed]
17
Spencer C, Randic L, Butler J. Survival following Profound Lactic Acidosis and Cardiac Arrest: Does Metformin Really Induce Lactic Acidosis? Journal of the Intensive Care Society 2009; 10: 115–7. [Source]
18
Funk G-C, Doberer D, Sterz F, et al. The strong ion gap and outcome after cardiac arrest in patients treated with therapeutic hypothermia: a retrospective study. Intensive care medicine 2009; 35: 232–9. [PubMed]
19
Spencer C, Butler J. Survival after cardiac arrest and severe lactic acidosis (pH 6.61) due to haemorrhage. Emergency medicine journal : EMJ 2010; 27: 800–1. [PubMed]
20
Di Rollo N, Caesar D, Ferenbach DA, Dunn MJG. Survival from profound metabolic acidosis due to hypovolaemic shock. A world record? BMJ case reports 2013; 2013. DOI:10.1136/bcr-2012-008315. [PubMed]
21
Ganga HV, Kallur KR, Patel NB, et al. The impact of severe acidemia on neurologic outcome of cardiac arrest survivors undergoing therapeutic hypothermia. Resuscitation 2013; 84: 1723–7. [PubMed]
22
S F, F H, S W, W S, G P, G G. Prehospital measurement of arterial base excess and its role as a possible predictor of outcome after out-of hospital cardiac arrest. Emergencias 2013; 25: 47–50. [Source]
23
Ncomanzi D, Sicat RMR, Sundararajan K. Metformin-associated lactic acidosis presenting as an ischemic gut in a patient who then survived a cardiac arrest: a case report. Journal of medical case reports 2014; 8: 159. [PubMed]
24
Paz Y, Zegerman A, Sorkine P, Matot I. Severe acidosis does not predict fatal outcomes in intensive care unit patients: a retrospective analysis. Journal of critical care 2014; 29: 210–3. [PubMed]
25
Williams KB, Christmas AB, Heniford BT, Sing RF, Messick J. Arterial vs venous blood gas differences during hemorrhagic shock. World journal of critical care medicine 2014; 3: 55–60. [PubMed]
26
Smith SW. Cardiac arrest, severe acidosis, and a bizarre ECG. 2015. http://hqmeded-ecg.blogspot.dk/2015/01/cardiac-arrest-severe-acidosis-and.html.
27
Park JS, Lee BK, Jeung KW, et al. Reliability of blood color and blood gases in discriminating arterial from venous puncture during cardiopulmonary resuscitation. The American journal of emergency medicine 2015; 33: 553–8. [PubMed]
28
Spindelboeck W, Gemes G, Strasser C, et al. Arterial blood gases during and their dynamic changes after cardiopulmonary resuscitation: A prospective clinical study. Resuscitation 2016; 106: 24–9. [PubMed]
29
Allyn J ’er\^ome, Vandroux D, Jabot J, et al. Prognosis of patients presenting extreme acidosis (pH \textless7) on admission to intensive care unit. Journal of critical care 2016; 31: 243–8. [PubMed]
30
Llitjos J-F, Mira J-P, Duranteau J, Cariou A. Hyperoxia toxicity after cardiac arrest: What is the evidence? Annals of intensive care 2016; 6: 23. [PubMed]
31
Ilicki J, Dj\arv T. Survival in extremely acidotic cardiac arrest patients depends on etiology of acidosis. Resuscitation 2017; 113: e25. [PubMed]

The post Extreme acidosis – how low can you go? appeared first on scanFOAM.

SWEETs17 ST-dag recap

Guest post by Jonas Willmer.

 

Första dagen är till ända och våra hjärnor är proppfulla med ny kunskap och nya erfarenheter! SWEETs FOAM-team består av Mads Astvad och Sandra Viggers från scanfoam.org, Thomas Dolven från scancrit.com, Jonas Willmer från akutmottagningen.com och Julia Sheffield ordförande i SWESEMjr.

Dag ett bestod i ST-dagen, för och av ST-läkare,

och fyra olika spår med workshops för övriga. Vi kommer fokusera på ST-dagen, som organiserades helt perfekt av Nadja Faris och Jens Wretborn, i det här blogginlägget och workshopsen snackar vi mer om i podden.

ST-dagen

PVK – The spilling of beans – Lillian Ihrman

Får du inte in en PVK? Prova v. jugularis externa. Om svårt att se kärlet så komprimera med fingret där du tror att det går så fyller det på sig. Bästa stället för att sticka ultraljudslett är v. basilica i överarmen.

Stoppa skalpblödning och andra life hacks från Sydafrika – Jonathan Pontén

Vi fick en färgstark beskrivning av jobbet på akuten på Khayelitsha hospital utanför Kapstaden med en rad smarta life hacks anpassade till den lokala miljön.

Skalpblödning som inte slutar pulsera och gör det svårt att sy? Knyt ihop två gummihandskar tumme till tumme och lillfinger till lillfinger och trä på huvudet. Stryper arteriell tillförsel till skalpen och ger dig en chans att suturera.

Om du vill tvätta ett sår noga utan att behöva oroa dig för blodstänk så ta den största spruta du hittar och sätt på en urinkopp som du gjort hål i botten på. Håll över såret och spruta med högt tryck utan att det stänker ett dugg!

Sätt EKG-elektroder vid varje skotthål innan DT för att se alla in- och utgångshål. Om ojämnt antal hål, leta kula!

Övervak utan telemetri? Lägg inte dåliga patienter ned i en säng. Låt dom sitta, ramlar dom ihop så behöver dom reevalueras..!

Vill du höra mer om Khayelitsha och hur du kan förbereda dig inför extrema utmaningar så spana in den här sidan.

 

 

Killers under graviditet – Haydar Al-Dhahir

Gravid kvinna med ST-höjningsinfarkt?

Dissektion i koronarkärl vanligaste orsaken så trombolys och antithrombinogen behandling är kontraindicerat. Allt annat ska ges inklusive ASA, clopidogrel och morfin.

DVT/Lungemboli under graviditet?

  • Vanligaste lokalisationen för DVT vid graviditet är i bäckenet på iliacanivå. 72%!
  • CT lungemboli ökar risk för bröstcancer hos gravida som har känslig bröstvävnad. Scintigrafi är bättre för gravida kvinnan men mer strålning mot fostret.

Pragmatisk klinisk praxis:

  • <35 år som vill bli gravida igen -> Scint
  • ->35 år som ej vill bli gravida igen -> DT

 

Akutsjukvård i minusgrader – Hannah Sjöstedt, Emilia Tiala.

Fallgropar när du tar hand om hypoterm patient:

  • Afterdrop – Kallt blod från periferin blandar sig med centralt blod. -> Undvik afterdrop genom att inte värma upp patienten för snabbt!
  • Uppvärmningschock pga vasodilatation.
  • Arytmier – Ta ej carotispuls! Kan utlösa arytmi! Kontrollera rytmen noga innan kompressioner påbörjas vid misstänkt hjärtstopp. Finns det en väldigt långsam rytm så kan kompressioner inducera ett VF. Deffa ej <33 grader.

 

Wireless vitals – New methods for large scale patient monitoring in the ED – Daniel Wilhelms

Daniel gav en liten exposé över den medtechforskning han är involverad i och uppmanade de som vill komma igång med medtechforskning att kontakta honom på daniel.wilhelms@liu.se

  • RespiHeart – Liten dosa som läggs på sternum och mäter hjärtfrekvens, AF, saturation.
  • Tapchart – Smidig akutjournalsapp. Klinisk prövning på gång.
  • MedTalk – sökorsaksbaserad översättningsapp.

 

Barnakutläkare i Sverige – Johan Smedbäck

Barnakutläkarföreningen, BALF, är på gång och kommer startas officiellt under våren. Barn utgör 20-25% av alla akutbesök i Sverige och socialstyrelsen säger ju att vi ska ha samma kompetens när det gäller barn som vuxna men i Sverige träffar många akutläkare inte dessa patienter till vardags. Hur ska vi få det att gå ihop?

BALFs huvudsyfte är att höja kvaliteten för barnakutsjukvård i Sverige.

Maila Malin.ryd-rinder@sll.se om du vill ha mer information eller vill vara med!

 

Målbeskrivning för dummies – Vibeke Manninge-Hammarlund

Vibeke har tagit fram ett kompendium för att underlätta för alla ST-läkare som mailas ut till alla deltagare så om du inte var på SWEETs, fråga dina kollegor som var här för att ta del av godbitarna!

ST-dagen – Workshops

Under eftermiddagen hölls tre introducerande föreläsningar om yrsel, ultraljud och NIV och sen delades deltagarna upp i mindre grupper och roterade på olika stationer och fick träna på det de just lärt sig.

Yrsel Get the HINTs – Nadja faris

Huvudbudskapet under Nadjas föreläsning och påföljande workshop var att yrsel är KUL när du har koll på vad du håller på med. Här kommer en snabb genomgång och en mer heltäckande blogpost kommer på akutmottagningen.com under kommande veckor.

 

Instruktionsvideo om HINTS

Diagnostisera och behandla BPPV i alla båggångar.

Flödesschemat för yrselpatienter i Lund.

 

Ultraljud – Är tanken tom – Niclas Lewison

  • Bedöm hjärtat, lungorna och vena cava inferior med ultraljud och väg ihop bilden för att bedöma patientens vätskestatus. Enbart vena cava inferior är inte tillförlitligt. äkrare vid hypovolem chock än distributiv chock.
  • CVP funkar inte för att bedöma vätskestatus på ett tillförlitligt sätt.

 

  • Har du svårt att se lungsliding? Dra ned gain rejält så blir det lättare.

 

 

 

 

 

NonInvasiv Ventilation – Jonas Westman

Var inte rädd för att initiera behandling med NIV. Sätt på masken och titrera upp.

CPAP – lungödem!

Börja med 5-15 cm H2O PEEP och titrera FiO2 till målvärde för saturation. Börja på 30-40 % och titrera upp eller börja på 60-80% och titrera ned.

Bilevel – hyperkapni (KOL!!)

Börja med 10/5 PEEP/PIP. Behandlingsmål med NIV: Normalisera pH, minska pCO2, Öka pO2, minska andningsarbetet.

Recept för att lyckas med NIV

  • Kompetent (van) personal
  • Prata, förklara och lugna patienten
  • Lugnande läkemedel vid behov
  • Stanna hos pat
  • Höjd huvudända 30 grader -> Minskat intrabdominellt tryck och minskat andningsarbete
  • Rätt storlek på masken.
  • Ha en plan B.
  • Utvärdera alltid med blodgaser men ffa kliniskt status

 

Podcast SWEETs17 day 1 recap

The post SWEETs17 ST-dag recap appeared first on scanFOAM.

Das Teaching Course in Copenhagen – The what, why, how?

What?

Most people in medical education who’ve tapped into social media and the #FOAMed world will know The Teaching Institute and many educators from its faculty.

For those not in the know, The Teaching Institute is founded and led by some of the finest purveyors of medical education in the US, Rob Rogers and Salim Rezaie. They have helped push and modernise medical education in numerous ways for years, but the teaching courses they’ve developed and run have been the main influence for a lot of people, me included. While they started this course in the US, it has grown and become increasingly international both with regard to faculty and delegates. It’s now delivered around the world by a global faculty of world class educators.

It’s thrilling to be able to say it’s now headed for Copenhagen, June 21-23. It’s the week before #dasSMACC in Berlin, hence the nickname DasTeachingCourse (#dasTTC for you tweeps). Its perfect for combining the two if you’re flying into the region. Most of the faculty is headed to SMACC to run workshops or talk, so this will be like 3 intense educational workshop days of SMACC in case you missed out on a ticket.

It’s being hosted in central Copenhagen. Not a bad place to be in June.

Why?

Education is changing at a fast pace these years. The whole #FOAMed movement with its vibrant online community has redefined how we share knowledge and connect about education. Tried and tested modalities like bedside teaching, lecturing, work shops, procedural training and journal clubs are being supplemented by new modalities like simulation and the flipped or mixed classroom. Content is being shared on blogs and/or as podcasts and video, and social media are increasingly where learners and educators interact which has opened new possibilities, but also poses some challenges. Every member of the faculty have been at the forefront of defining education for this new age by using, developing and scrutinizing these new digital avenues. This course covers it all, from the tried and tested to the most innovative of platforms and modalities.

I went in 2015 and it was like no other course I’ve been to. The faculty are true experts and genuinely passionate about helping others improve their game. I’ve never experienced such a perfect mix of uber prepared talks and well planned work shops. It was all tied together by a strong motivation in both faculty and delegates for improving education and hence patient care. That provided a unique energy and vibe and people from all over the world really learned and connected.

The line up for Copenhagen is as strong as ever and counts Nat, Simon, Chris, Jesse, Sandra, Ashley, Ross, Will, George, Salim, and Rob. You’d be hard pressed to find a better crew to take your educator skills to the next level.

For a taste of what you’ll find, check their profiles and their work on various online outlets, and also make sure to check our previous posts about the teaching course (content from TTCNYC15, Sandra’s recap from TTCNYC16 Day 1 and Day 2, and Camillas guest post with impressions as a #FOAMed neophyte). Twitter also has a lot of activity during these courses (try this feed for a taste).

For me, the primary benefit to having been is having met so many awesome educators (my scanFOAM partner Sandra being one of them!). It’s all about connecting minds and ideas which comes down to connecting people in the end. With social media the connections formed at this course linger on and the conversation just keeps going. It never really ends. The question is if #dasTTC is where it starts for you?

If you’re involved in medical education and want to improve, I think it’s a no brainer. Come join us in wonderful Copenhagen 4 short months from now. It’s not all rotten in the state of Denmark. We are after all the happiest nation on Earth. Come see why. And join the educationalist party.

How?

Easy: Sign up!

 

Here’s a teaser for the most recent course in NYC.

Very best

/Mads

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Camilla Goes To #TTCNYC16

ttcnyc16

The scanFOAM team loves SoMe and all of our “internet-friends”, so much so that we want our “real-life-friends” to meet our “internet-friends” when opportunities arise. Therefore, Camilla stood no chance after a few times having said “That twitter, blog, smacc, podcast -thing.. teach me, show me, I want to know more!”. A link to The Teaching Institute was sent her way with the words “come with me to TTC” and boom! Camilla was set up to join me and the rest of the crowd in NYC.

Read on below for her first guest blog post where she describes her experience from this most wonderful time in NYC.

/Sandra


A beginner’s guide to The Teaching Course

Wonder what to expect when signing up for this 3-day course full of innovative teachings? Well, those were my thoughts exactly as I curiously signed up for my first non-virtual encounter with the world of #FOAMed.

I wanted to go because I often find myself uninspired after attending educational sessions. I generally have a high intrinsic motivation to learn, but that motivation is often lost in boring lectures and teaching interventions that don’t inspire. I dislike the way this makes me feel and it makes me wonder if sometimes I have that same effect on my learners.

I was looking for a place that could teach me better ways to engage learners. People who could lead the way and inspire me, be innovative and creative and shake things up. On top of that I hoped to connect with people in the process and gain new friends for continuous development.

So, having been, here is my list of what you can expect should you wish to embark on this journey yourself.

Expect to experience a deeply passionate and committed faculty

Passion was one of the keywords at this course. And that passion was felt way before the actual course began, as emails started to hit me with embedded podcasts and relevant articles indicating that these educators practice as they preach about flipping med ed. Faculty started to tweet their excitement about attending #TTCNYC16 and a pattern started to emerge; these people truly love their job! And they are at least as excited to attend as the participants, if not more. That passion is contagious and as inner motivation and excitement increase you start to think – hey, I actually do want to prepare for this course using the flipped classroom material. We all know how this can be a challenge, but something about how they flip and the passion they do it with makes it work.

Expect to experience the most committed co-participants

The participants at this course are an amazing crowd of passionate and dedicated educators. Already ignited from the flipped classroom material I realized that this culture is one I’d like to be a part of – not only for the people I teach, but also for me personally. Most of the people you meet have this exited look in their eyes, and they come from all over the world and from many professions. Vets, medical doctors, nurses, pharmacologists and many more united in one place with one main focus: Flipping the world of medical education to a dynamic, engaging, and learner-centered environment 

This is therefore the place to grow your network – the workshops, the “talk to your neighbor for a few minutes” and the openness from all attendees it all allows you to make new friends. I know I met a few that are going to be for life.

Expect to be convinced about the fact that everyone hates (too many) bullet points and busy slides

True! As a medical student I figured that one out ages ago. But now I know why and what to do instead. I feel quite relieved that my presentation-related narcolepsy is maybe just a symptom of (boring) unstimulating lectures and conference presentations.

You will leave with a large toolbox to create better slides and more inspiring talks. Go to the Day 1 recap for more details on presentations.

Expect to feel embarrassed about your previous preparation time

Up until now my conference talks have been created maybe two weeks in advance and practiced in front of the computer. I have felt prepared, but always very anxious about how it would work out in front of the audience. Where should I stand, where should I put my hands, would my punch lines be well received or fall straight to the ground? The teaching course will teach you that preparation should start even earlier, be detail specific (where should I stand, when should I move, and so on) and importantly: Your presentation must be practiced out loud in front of a small audience who can give you feedback before the real deal.

Geeks are the new black. Being a nerd about your presentations and what you put into the world now strikes me as cool. Ask yourself: Wouldn’t you love it if a teacher or presenter thought that you deserved endless hours of meticulous preparation to teach you about the subject they care about?

Expect to be surprised about the cultural differences

Not surprisingly some cultural differences between the different nationalities present at the course are to be expected. From my point of view: It seems like in Scandinavia there is a more humanistic and learner involved approach to education. Learning is more of a process and a discovery and not so outcome related, evident in that we make much less use of testing and maybe to some extent trust our students and residents more to be in charge of their own learning. Neither approach is a holy grail, but there must be lessons for educators in examining differing approaches and their merits. Deliberately developing and optimising combinations of intrinsic and extrinsic motivation relevant to your context and culture, seems like a required path to excellent learning and for fostering excellent learners.

Expect to feel the power of motivation

The feeling of motivation can be almost overwhelming. So many things can be done you may not know where to start and what to choose to begin with on your own journey. Creating new slides for your presentation, opening a twitter account (yes, I truly am a newbie in this area of #FOAMed), better development of the curriculum, start podcasting, initiate better feedback procedures in your department, write blogposts and so on. You can’t do it all at once! And as many in the faculty pointed out – remember to take care of yourself. There will be a risk of burnout if you think you can do everything at once. Take care of yourself, online and offline, and logging off and looking up once in a while is recommended.

And then finally, expect to feel: S***, now what?

As the motivation grows and you look around and see all these inspiring people there is a risk of feeling sort of lost. I know I did. Figuring out what your role and your contribution in the #FOAMed and #SoMe world could be is maybe not as simple as Nike’s “Just do it”

screen-shot-2016-11-14-at-2-08-02-pm

But as in any new adventure, my role will evolve over time as I reflect on and process this igniting course. I feel this education environment will always welcome another set of dedicated hands. At the least it got me to write my very first blogpost.

A great big thanks to the faculty and the participants at the course for adding to my journey of becoming a better educator and a better learner. I feel blessed knowing that I now have a safety line and good people to turn to when I need help getting to the next level of educator awesomeness.

If you are considering going next year do know that there is room for everyone and that this could be the beginning of a very exciting journey.

 

/ Camilla

You can listen to more reactions on #TTCNYC16 from Camilla and others in this round up cast hosted by the St-Emlyn’s team:

We at scanFOAM hope we have inspired Camilla and hope that sharing this blogpost will get her to write even more with us. If you have a story or a topic you want to write about and think scanFOAM could be the place to share, please get in touch.

The post Camilla Goes To #TTCNYC16 appeared first on scanFOAM.

The Teaching Course NYC DAY 2 #TTCNYC16

8Innovation and the millennial learner

It will come as no surprise that innovation is a topic at The Teaching Course.

The faculty behind The Teaching Course are truly first movers and innovative educators so having Christopher Doty kick off the day with the importance of innovation and the millennial learner was very appropriate.

Just as day 1 was all about knowing your audience, in education and curriculum development it is all about knowing your learner!

And right now, many of us are involved in teaching “the millennial learner”. The characteristics of the millennial learner are:

  • Hard working
  • WIIFM (What’s In It For Me)
  • Want to know what the impact is of the educational options they are exposed to. Answer this for them with relevance and they will engage
  • Collaborative – and learn through social interaction (on- and offline)
  • Not that good with negative feedback, as in not at all!! They aren’t used to it and it will block their ability to learn

Since millennials have these preferences and prefer social interactions and active learning strategies, please no more lecturing + death by powerpoint. They won’t respond well. Rather, engage your learners with active strategies such as case based learning, flip the classroom, simulation, and other experiential learning methods.

In case you want a theoretical educational viewpoint, take a look at connectivism. Connectivism might not qualify as a true theory yet, but it describes very well the learners of today, their preferences in learning and what they expect their educators to know.

On a personal note, you can call them millennials, generation why? or just learners. This is not necessarily related to age. Nat May wrote an excellent post about this that I think all educators should read.

When designing curricula for these millennials, Christopher gave a concrete example of how basic technology skills will get you far and straight to the hearts of millennials (their hearts, in case you wonder, being their apple devices!)

He showed us how he had set up a simple calendar with links to core content and suggested background material embedded in the calendar event – such a simple yet excellent idea, a great take home message and easy to implement even if you are not a millennial yourself.

img_2381

The discussion went on about how “learner centered” approach was important, but maybe not quite easy to figure out and how “flipping the classroom” seemed to be the go-to teaching method for this group of learners. With that though comes new challenges, e.g. difficulty in getting learners to actually read pre-course material.

So, what is a learner centered approach?, and should we maybe move all the way to a “learner involved” approach? Maybe it’s time that we as educators adapt to the learners instead of just molding them into our curriculum?

On a personal note this is a topic of great interest to me and I know I already referred to it yesterday. If you’re curious on how learners of today can be motivated and facilitated go back to the Day 1 recap and check my smaccDUB talk which has details on education theory and novice learners in it.

 

Teaching Evidence Based Medicine

After a group discussion by the participants we moved on to the topic of Evidence Based Medicine. Ken Milne from The Skeptics Guide to Emergency Medicine took the stage to educate us on how to teach evidence based medicine so it doesn’t suck (his words not mine!).

With gracious elegance, passion and humor he carried us through the 5 topics of the talk

  1. Definition of EBM
  2. The Venn diagram
  3. The history of EBM
  4. The 5 steps to critical appraisal
  5. Limitations to EBM

Definition:

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making (shared!) decisions about the care of individual patients.

and is nicely summed up in this Venn diagram made by Salim:

screen-shot-2016-11-15-at-9-12-31-am

The history of evidence based medicine was played out in a beautiful run through history involving the #TTCNYC16 participants and walking us through the story of Alexander Hamilton (to illustrate randomization), Franz Mesmer (who taught us to be aware of being mesmerized and instead make use of blinding) and Marie Antoinette and Louis the XVI as the skeptics.

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Biases and the power of placebo was demonstrated by a brave (and strong and fit!) participant.

Everything was wrapped up asking: What if we didn’t have EBM in EM? Would this be what it would look like in our EDs?

 

Then Ken introduced us to 5 steps to critical appraisal:

  1. Identify the PICO question
  2. Search for the literature
  3. Rank the literature in the evidence hierarchy
  4. perform critical appraissal
  5. And finally ask if it’s a game change and how you can use the findings to change clinical practice.

If you want help on how to search for literature and an illustration of the hierarchy of evidence just follow the links!

Finally, we were reminded of the limitations to EBM

  • Some things are self-evident
  • If it is harmful- it is unethical so don’t do it! (the parachute trial!)
  • Most research findings are wrong!
  • Most guidelines lack strong evidence!
  • And… we tend to ignore good evidence

The take home message

  1. EBM Rocks!
  2. It all depends!
  3. Be skeptical – even if you learned if from theSGEM!

AND it is possible to teach evidence based medicine so it doesn’t suck!

Head over to TheSGEM’s webpage and learn more about critical appraisal and EBM.

Meta level feedback for Ken from me: As a lover of EBM and recently having designed a curriculum for teaching medical students evidence based medicine in EM – you absolutely nailed it. It brought tears to my eyes and the applause from the audience makes me confident I was not the only one!

 

Curriculum development

After Ken’s inspirational theatrical EBM performance piece, we went on to the curriculum development session.

Jeff Riddell introduced to Kern’s six step approach to curriculum design:

  • Problem identification
  • Targeted needs assessment
  • Goals & Objectives
  • Educational strategies
  • Implementation (resources & barriers)
  • Evaluation & Feedback

sixstepapproach

Then it was time for the workshop part were groups had to design a curriculum in cardiology for residents.

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Feedback from the group discussion:

  • Generating learning goals is difficult.
  • Remembering that learners only have a set amount of time available for learning is important – so you can’t cover everything at once.
  • Designing curricula that covers the needs of the specialty and the department and at the same time are learner centered is a true challenge filled with individual and organizational barriers.
  • Solving all (and more!) of these problems in curriculum design can be facilitated by turning to learning theory.

Read this learning theory 101 publication for inspiration on how to aid learning at your institution.

 

Self care

As an extra treat the TTC faculty threw in a bonus post lunch talk by Iain about the well-being of health care professionals

Iain shared a strong and effective story of how you need to take care of yourself so you can take care of others. And how taking care of others is also taking care of yourself.

We need to monitor our wellbeing. Sometimes we go to work hungry, angry, lonely, and tired! When that happens STOP!

stop

Find some coping strategies that can change your mood from angry to happy. For Iain, it’s music; for you, it could be something else. Make sure to eat well and healthy before, during and after shifts. If you’re lonely – find a friend – or be a friend to someone you think seems lonely or sad. Pay attention to sleep! Get enough sleep. On a daily basis….

Ask yourself “are you adequately rested and fit to treat patients?” And you, you!, are responsible for helping grow a culture where calling in un-fit is ok.

After a very emotion filled and emotion triggering performance we went on to another favorite must-happen topic on #TTCNYC16:

 

How about infusing Social Media into your curriculum?

Jeff talked to us about the what, why & how of your learners using #FOAMed as an adjunct or maybe even as a substitute to the established curriculum.

1. What are our learners using

Podcasts, blogs, twitter, youtube, instagram, snapchat, wikipedia, apps, google, up to date, e-learning/books/journals, icloud/ other file sharing software.

Podcasting seems to be increasingly popular with about 90% of our learners being particularly fond of this type of outlet.

Our learners subscribe to about 2,5 podcasts and prefer a length that is below 30 minutes. When asked if podcasting change their clinical practice, 75% answer yes. Remember they listen to podcasts primarily while driving or exercising and therefore are not able to pay undivided attention.

 

podcast-old-microphone-placed-on-office-desk

 

2. Why are they using it?

whypic

Here are some of the very good reason given by the group of participants to why our learners are engaging in social media:

  • to assist diagnosing
  • to learn how to perform procedures
  • to find treatment options
  • to find help with board review / core content
  • to keep up with literature, networking, cutting edge ideas and innovation
  • to learn radiology.

3. How do they make decisions on what content to consume?

They have seen it in the clinical space (80%), or it’s been pushed to them, and/or they use what faculty or program directors recommend.

A few words of advice for us as educators when we prepare and disseminate content:

They primarily find content on facebook and twitter! Many educators join #FOAMed on twitter – but you should consider making a facebook page or facebook group because that is where they are.

When planning content know that their reading patterns are FAST and F-shaped when measured with tracking devices. Plus, they read most of the content on their mobile devices…on the go!

The average time spent on a webpage is about 2-3 minutes. Boom! That is the amount of time you have to deliver a message (yep, this post is waaayyy to long, but luckily you are a very intrinsically motivated and interested audience ;-)). Right?

To consolidate what they’ve read and listened to, invite learners to interact and engage outside of social media. Have a “what did you learn on SoMe – club” where discussion and reflection are emphasized.

After this appraisal of social media in medical education, the next question was

 

Is #FOAMed making you stupid?

and Will Sanderson tried to help us answer that question.

In short: It just might, if we are not careful.

In 2007 when the iPhone was introduced the world changed! We got access to everything, everywhere, anytime.

And from then on not having internet would scare the s*** out of us. Ask yourself: Are you addicted to the internet?

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Ask: Is all that time spent on social media really good for you? Your family? Your relationships? Your patients?

Or are those “free” social media apps really weapons of mass distraction?

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If you don’t pay attention to how you consume social media you might just get stupid from it. Because they will challenge your attention span (damn you, notifications) and ruin your sleep (that blue light!). Furthermore, because you generally spend very short time on each topic they don’t really facilitate deep work and reflection.

The message here is not to avoid or stop using social media – it’s about using them wisely.

Avoid information overload as with all information channels these days. Turn off notifications when you work and reflect and hang out with your family. Design your learning networks so you receive relevant information (and diverse enough to avoid echo chamber effect). Keep personal accounts separate from learning accounts and use work apps that allow for offline use so you don’t get patient care interrupted by your phone vibrating in your pocket.

 

Afternoon sessions

The afternoon had 2 tracks to choose from, track one being “Advanced podcasting” and track two “Advanced curriculum design”.

I went for the podcasting section and that was truly an awesome session. I’m not going to blog too much about it here – that would be so wrong. So stay tuned as the scanFOAM team embarks on a new adventure into the world of podcasting and soon will be sharing our very first episode with take home messages from this session.

I will say, though, that the workshop was led by an awesome faculty with serious knowledge skills and an impressive passion. They taught us all about the technical details of microphones, editing software and more importantly CONTENT! To learn about podcasting from this amazing crew was truly a very special experience. Thanks for sharing your knowledge, guys!

For those of you that want even more on this topic, remember The Podcasting Course in Kentucky in April – I know I need to go home and see if I can figure out leave somehow.

Since I didn’t attend the curriculum development session I can only refer to the above description of Jeff’s talk and workshop and to Jordana’s talk described in the Day 1 recap.

Twitter to the rescue: Look up #TTCNYC16 – seems like a lot of great content came out from that workshop in people’s tweets:

And there you have it – my take of day 2 at TTCNYC16 (well, there was also #FOAMaoke, but some things are just best kept off the internet).

Thanks for stopping by. Please share, comment and give feedback. It’s highly appreciated.

To figure out where you can go sign up to a Teaching Course event near (or far from!) you, go to the Teaching Institute wepbage for more information.

Time to get out of bed and head over to the innovation loft to prepare that day 3 recap for tomorrow!

Vb

/Sandra

The post The Teaching Course NYC DAY 2 #TTCNYC16 appeared first on scanFOAM.