Episode 24: What do I read, and how do I do it?

In Episode 24, EM Res vets Drs. Kaminstein and Kochert return with Dr. Becker’s debut to talk about how residents should approach reading medical research articles.  Do you need to read everything?  What should you read?  How do you do it?  All this and more in the first of a series on reading original research for residents.  

The first thing you need to know is that if you are an intern, and maybe even a second year, it is ok if you are not keeping up to date on the latest and greatest in original EM research.  The most important thing you can do during this time is to cover the basics.  Develop your basic knowledge and skills in EM.  

Once you do delve into research, pick one or two journals to start out with.  Annals of EM and Journal of EM come to mind (full disclosure: I am on the Annals Social Media team, and on the AAEM YPS board).  Once you have a journal or two, skim the titles and see what interests you.  If you see an interesting title, read the abstract and see if the full article is worth your time.  

Remember, once you start reading, the discussion is the writer’s chance to slant their results as they see fit.  There is a reason this section is last - it should be the least important part of your analysis.  

Think about articles in PICO format.  

P: What type of patient are they looking at/what is the patient population?

I: What is the intervention?

C: What is the control?

O: What are the outcomes?

This should give you the foundation to start.  This is the first in a series of podcasts where we will cover more advanced topics so that you too can be able to critically read and appraise the medical literature by the time you are done with your EM residency.  

Here are some great resources cited during our discussion:

The Skeptics Guide to EM

Emergency Medicine Abstracts

EMCrit

EM Literature of Note

EM Nerd

EM Journal Watch

EM:RAP paper chase

SMART:EM

A few announcements:

  1. I have been away for the last month working on Emergency Board Review!  Go check it out.  Check out our latest review lecture on nervous system disorders.  Find the lectures on our podcast on iTunes, or any podcast software.  Check out the revamped website, rate the board review resources, and get involved.  Are you an upper level resident and want to help out with the Emergency Board Review project?  Get in touch with me at bobstuntzmd@gmail.com, or use the website contact form if you are interested in any of the open topics
  2. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  3. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  
  4. Allowed to use my podcasts for asynchronous learning?  Check out the test below!

Check out the podcast below, or go listen here


If you have gotten approval from your program director to use the EM Res Podcast for individualized interactive instruction (asynchronous learning), the check out the test below or go take it Posted in , , , |

Episode 23: What’s the “Best” Residency?

In Episode 23, with the upcoming US EM residency interview season about to descend upon us all, I talk about a recent survey that claims to list the best EM residencies, why you should ignore it, what applicants should look for in a residency, and our duty as educators to find the right fit.  

f you are a medical student going into the EM Match this year, check out the following great videos to see what you should be doing, and how you can be the best applicant you can be:

The EM Rotation, ERAS, and am I competitive

Interviewing Strategies

Here is the original link I saw to the list of top EM residencies as compiled by Doximity and USNWR’s survey

ere is a link to the consensus document regarding the problems with this report. 

Announcements:

  1. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  2. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  

Listen here or check out the podcast below:

Episode 22: Do an H/P, But Don’t Forget Ultrasound

Episode 22 is a response to an article on KevinMD from April 2014, "Forget Ultrasound, Do a Proper History and Physical Instead."  In this article, written by a radiologist, Dr. Saurabh Jha (@roguerad - follow him.  I do, very interesting thoughts and perspective), the argument is made that POC US is being done indiscriminately, instead of a good H/P.  Amongst other things, the article concludes that POC US is bad for patients, costing taxpayer money and leading to over testing and over diagnosis.  POC US has been similarly accused recently in regards to leading to over testing (see this thought provoking post from EM Nerd).  Dr. Jha’s article was originally written in response to this article from NEJM, which sang praises for POC US, but did have some mischaracterizations.  

Admittedly, we may have overall overreacted a bit to this article as can be seen in the comments (the title alone is inflammatory, but frankly KevinMD often is recently).  Dr. Jha made the following clarification in the comment section:

"I’m advocating against indiscriminate use of ultrasound, as routine, as a substitute or extension of H & P (see NEJM article), not against selective use of imaging within clinical context."

We agree in some respects:

  1. We should all absolutely be doing a good H/P, and using US as a diagnostic test in the clinical context of our patients.  
  2. We should all be properly trained. 
  3. US is not a simple, learn this overnight kind of thing.  It takes dedicated training, and constant learning and practice - which we do well in the POC US community. 
  4. The US is not a stethoscope, nor is it an extension of your physical exam, and should not be used indiscriminately.

But, the physical exam is not so great:

  1. How good is a Rovsing’s sign?
  2. How about a Homan’s sign?  See here or here
  3. Murphy’s sign?

One thing we do know is that POC US does have a positive impact on patient care through faster door to diagnosis times, faster throughput, and improved patient satisfaction, based on previous POC US studies.  

Announcements:

  1. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  2. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Great discussion this week on ketamine for post intubation sedation. 
  3. Tumblr Users: I’m aware of the video issue and will do my best to get it to cross over.  Consider following the blog here at emrespodcast.org, or subscribe to the RSS feed.  Getting a bunch of new Tumblr followers recently, so want to make sure this is working out for you.  

Now, onto the Podcast:

Listen here or listen below:

Episode 21: You’re Not Alone

In this mini-episode, I talk a bit about an incredibly interesting and important article published recently in the New York Times regarding resident suicide and depression.  The bottom line: If you feel like you need help, you’re not alone.  

Check this sobering article out here

Two quick announcements:

1.  Are you interested in helping write for or participate in the EM Res Podcast and blog?  I am looking to expand the blog and podcast, and I’d love for you to help.  Have an idea for a blog post?  A series?  Podcast ideas?  email me at bobstuntzmd@gmail.com, and let me know what you think.  Residents and educators welcome.  

2. Thanks to everyone who has joined the EM Res Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  It gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  Feel free to post items, comment, and share.  

Now, onto the episode:

Episode 20: COPD Part 2

Episode 20 is Part 2 of Dr. Kochert’s lecture on COPD.  In Part 2, Dr. Kochert discusses the tough question regarding antibiotics in COPD exacerbations, smoking cessation in the ED, and finishes with a Q/A discussing some of the finer points of the lecture and managing COPD patients.  Thanks again to Dr. Kochert for allowing me to post his lecture.  Making a great lecture like this takes a bunch of work, and he gives a great comprehensive review.  

Here is the final summary for the whole COPD talk:

  1. Titrate oxygen on patients with COPD exacerbations to achieve saturations of 88-92%.  Want a more detailed discussion with references?  Check this out
  2. Steroids should be given for all patients with COPD exacerbations.  Prednisone 40 mg PO x 5 days seems to be a reasonable dose.  
  3. Have a low threshold for non-invasive positive pressure ventilation (NIPPV).  It has been shown to reduce mortality and intubation rates.  jump on it early.  Again, as discussed in Episode 19, there has not been any great evidence to show CPAP or BiPAP is better.  Talk with your friendly neighborhood respiratory therapist and see what the standard is at your shop.  
  4. The evidence for antibiotics is not totally clear, but, based on available evidence, give antibiotics to:
    • Patients admitted for COPD exacerbation (especially intubated patients)
    • Outpatients with purulent sputum
  5. Discuss smoking cessation in the ED.  This is a teachable moment.  As Dr. Kochert said, peri-intubation may not be the best time, but otherwise this can definitely impact patients in a positive way.  

Two Reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. Below you will find the III/Asynchronous Learning Quiz for Episodes 19/20.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  

Remember, if you have feedback, or questions for me or Dr. Kochert, I want to hear from you!

Email: bobstuntzmd@gmail.com

Twitter: @BobStuntz

Google+

References

  1. GOLD: http://www.goldcopd.org
  2. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD): http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764.pub2/abstract
  3. New, A.  Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient.  Emerg Med J. 2006 February; 23(2): 144–146.

  4. Austin MA et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ 2010 Oct 18; 341:c5462.

  5. Quon BS, Gan WQ and Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and meta-analysis. Chest. 2008; 133:756–66.

  6. Leuppi JD et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA 2013;309:2223. [PMID: 23695200]

  7. Nouira S, Marghli S, Belghith M, Besbes L, Elatrous S, Abroug F.  Once daily oral ofloxacin in chronic obstructive pulmonary disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial.  Lancet. 2001 Dec 15;358(9298):2020-5.

  8. Miravitlles M, Moragas A, Hernández S, Bayona C, Llor C.  Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment?  Chest. 2013 Nov;144(5):1571-7. doi: 10.1378/chest.13-0518.

  9. http://www.acep.org/Clinical—-Practice-Management/Smoking-Cessation/

  10. Prochazka A, Koziol-McLain J, Tomlinson D, Lowenstein SR.  Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.  Acad Emerg Med. 1995 Mar;2(3):211-6.

  11. Katz DA, Vander Weg MW, Holman J, Nugent A, Baker L, Johnson S, Hillis SL, Titler M.  The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling.  Acad Emerg Med. 2012 Apr;19(4):409-20. doi: 10.1111/j.1553-2712.2012.01331.x.

Enjoy the podcast!


Get the OK from your PD?  Get Asynchronous Learning credit for listening!

Are You Ready for Some…C Spine protection?

It is that great time of year.  Sure the kids are going back to school, but more importantly, football is back.  And with that, your ED may soon be filled with folks on backboards wearing full football attire, taped down for c-spine protection.  How do you get their helmet and those pesky shoulder pads off while maintaining c-spine precautions?  Check out the video below, which does a great job demonstrating how to do just that.  The video is courtesy of Dr. A.J. Monseau.  Dr. Monseau is the Assistant Program Director at the West Virginia University Emergency Medicine Residency, and a sports medicine specialist.  A few of the WVUEM residents show us how it is done. Make sure you are following them on Twitter:

Dr. Monseau: @EMedSportsDoc

WVUEM: @WVUEmergencyMed

Definitely give Dr. Monseau’s YouTube page a view as well - he has some great splinting videos.  

Also, please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.