08.28.12
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ACEP US Section Discussion Forums

If you aren’t a member of the Ultrasound Section or ACEP this is a great reason to become one.

 

Screen Shot 2012 08 28 at 10.48.26 AM 500x223 ACEP US Section Discussion Forums

 

Mike Stone with help from Phil Perera and no doubt others have built a forum where you can find all of the most pertinent discussions from the section list-serve. There are a few choice topics available for your perusal and comment right now, but I’m sure this will be built into an even better resource in the future. Great Job.

 

To find the forums, head to the acep ultrasound section page and look for “ultrasound forum”.

08.28.12
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Forearm Rolling Test for Stroke

Testing for arm drift is a standard part of the simplified three-part neurological exam we all perform, technically called the Cincinnati Prehospital Stroke Scale. It’s a fairly crude examination, but when even one finding is positive in the right clinical scenario, there’s a pretty good likelihood that the patient has experienced a stroke. The problem is that testing for arm drift isn’t perfectly sensitive and it will miss a certain number of acute lesions that could be amenable to treatment.

One way to increase the yield of the physical exam is to expand beyond the basic maneuvers we are taught early in training. Doing so, however, has costs in terms of time and memory, two things we are often short of in emergency medicine. We can’t afford to be doing complete neurological exams, nor remember the numerous steps involved, but by adding a couple of simple, high-yield maneuvers to our repertoire we can really improve our patient assessment.

Arm Drift in Summary

First, let’s review what we’re already doing. The finding we really want to elicit with arm drift testing is actually called pronator drift, which has a bit more to it than just looking for unilateral arm drop. Like we all know, you start by having the patient hold their arms straight out in front of them at the level of the shoulders for 10 seconds (or 20, or 30, depending on who you ask). The trick most people know but don’t always utilize is that the patient’s eyes should be closed and their palms pointing towards the ceiling. If you’re not doing these last two parts, you’re giving up valuable information. A positive test will usually exhibit an inward rotation of the patient’s affected hand (pronation), plus-or-minus downward arm movement. In certain cases, however, you may actually see the affected arm move upwards; just know that a normal person should be able to keep both hands parallel. I also like to tap their hands downward after several seconds to look like I’m doing a deluxe exam and see if I can provoke any subtle weakness.

The Alternative

So onto our new concept: the “forearm rolling test.” Unlike most signs in medicine,  I don’t believe this one has a fancy eponymous name meant to confuse medical students. To perform the exam, you have the patient hold their arms in front of them with their elbows bent at 90 degrees and forearms parallel to the ground. The patient rotates their arms around one-another in a circular motion for 5-10 seconds, then reverses direction. A positive test will result in the affected arm remaining fairly stationary while the good arm circles it. Pretty straightforward.

Forearm rolling test. Click image for source.

So below is the only video I could find on the internet demonstrating the maneuver. For best results, I suggest having your partner play a hand drum while you perform the exam. Glittery belts are strictly off-limits unless you are an attending neurologist.

Forearm Rolling (sorry I couldn’t get embedding to work)

The Evidence

I first came across this exam in a wonderful book called Evidence-Based Physical Diagnosis. For the forearm rolling test they listed a sensitivity of 87%, specificity of 98%, positive LR of 36.6, and a negative LR of 0.1 in identifying unilateral cerebral hemispheric disease. There’s not any discussion of the numbers outside of the table where they are listed, but they seem to come from a study by Sawyer et al in 1993.

Even without a full-text article available, it’s obvious that these numbers are too good to be applicable to a population outside of the very specific one studied. Still, the results certainly caught my attention and made a case for the arm roll being a potential useful tool. Reviewing a couple of textbooks and the abstracts from 3 or 4 other studies, the sensitivity of the test ranges anywhere from 24% to 98% depending on the population being studied. The important point is that it consistently outperformed pronator drift in the detection of cerebral lesions. It’s not perfect, but it’s probably an improvement.

There are two variations on the maneuver that I’ve come across in the literature, referred to as index-finger rolling and thumb rolling. The problem is that while they are mentioned fairly often, they are not well described and I don’t have access to any of the articles that might provide some elucidation. Why should you care about these? Well it appears that finger rolling may be even more sensitive for cerebral lesions than forearm rolling, with thumb rolling claiming an even higher sensitivity than both.

As a point of disclosure, I just came across these variations while researching this post and haven’t used either in clinical practice, but I will be certainly trying them in the near future.

Finger Rolling

CONJECTURE ALERT: My only source of information on how to perform this test comes from this one picture I stumbled across. It looks like it’s performed very similar to forearm rolling, but with the index fingers extended and the focus on rotating the hands as opposed to the entire arm.

Finger rolling. Click image for source.

Since most sources mention this as being superior to forearm rolling, I’m not sure why they even bother mentioning the latter anymore. Still, there’s not too much hard data out there so try out both and see what you like best. Here’s the one free full-text article I could find comparing the two, and a letter describing why it’s plausible that they could be useful in combination.

Thumb Rolling

DOUBLE CONJECTURE ALERT: I don’t even have a picture of this one to go off, but I’m going to assume that thumb rolling as described in the neurology literature is basically the act of twiddling one’s thumbs. Amazingly enough, someone put a video of himself twiddling his thumbs on YouTube, so here’s the enthralling link if you’re not sure what I’m talking about.

There’s only one abstract I was able to find on the subject. The premise is that since finger rolling is better than forearm rolling, examining the even more distal thumbs will provide greater sensitivity as they are more likely to be affected by a CNS lesion. Again, this is pretty limited data and all I can suggest at this point is that you try it out and see if you like it.

Conclusion

So how do I plan on using these tests? Since drift is a standard part of the Cincinnati Prehospital Stroke Scale and commonly understood by emergency care providers of all levels, I don’t see it being replaced by rolling. Using the two in tandem certainly seems like a good idea to me, with almost no downsides. All of the rolling tests are so quick and easy to perform that the only negative would be the risk of a false-positive result.

In my limited experience the false-positive rate is small, easily predicted, and no worse than what you see in pronator drift testing. In fact, I find the forearm roll is actually a bit easier for the patients to perform than pronator drift testing. We see a lot of folks who are either too weak and lethargic to hold both arms up for a decent amount of time, or don’t follow directions very well and get distracted after a couple of seconds, so 5-10 seconds of active participation by having them roll their arms usually works pretty well.

Finger rolling will probably be my new default maneuver over forearm rolling. The consensus in journal articles and neurology texts seems to be that it is more sensitive, plus I imagine that it also is a bit easier for the patient to perform. I’ll still have to try them out in tandem for a bit to make sure this pans out, but I don’t foresee any issues.

As for thumb rolling, I’m much less sure how this is going to fit in at this point. For now it will just be something I play around with when I have the opportunity. If I decide I like it, I’ll update this page to reflect my experience.

So get out there, do some exams, and let me know what you think.


08.28.12
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Maniobras vagales: la jeringuilla, el pinchazo…¡y la mariposa!

ECG 1
Fue una guardia entretenida, empezamos con esto: varón de 47 años, sin antecedentes de interés que acude por palpitaciones. Exploración física sin hallazgos, salvo taquicardia rítmica y signo de la rana evidente en el cuello, constantes normales.
Este era su electrocardiograma (ECG1) y mi diagnóstico el de taquicardia supraventricular a 200lpm.



Como ya os imagináis, canalizamos una vía e intentamos revertirla con la famosa maniobra de la jeringa de 10 ml: ¡sople, sople!, le dijimos, pero nada...esta vez no hubo suerte. Así que tras varios intentos y siempre con el paciente estable, esperamos a la ambulancia medicalizada para que lo intentaran con el habitual bolo de Adenosina. Cuando llegaron, decidieron coger una vía de calibre más grueso y optaron por un catéter del número 16, mientras cargaron también la medicación...y estaban a punto de pasarle el bolo cuando, probablemente por el estímulo vagal inducido por la inserción del catéter grueso, nos encontramos con esto (ECG2): ¡REVIRTIÓ!
ECG 2
...Y al cabo de un rato en observación, se fue a casita perfectamente perfecto y con este ECG:

ECG 3

Os dejo el enlace a un blog (eso sí: es en inglés) que nos llegó a través de los compañeros del PAC de Manresa, ¡gracias colegas!, en el  que hablan del uso de la, ya famosa, jeringuilla de 10ml utilizada en estos menesteres. Ya sabéis: si falla, siempre podemos probar con un catéter grueso...(Hace años, me tocó una situación que se resolvió de idéntica manera)

Vi otros casos interesantes y cuando bajamos a cenar, ya bastante tarde, nos encontramos con esta preciosa sorpresa adornando la blanca pared de nuestra sala/cocina: ¿a que es bonita? Afortunadamente, no todo es ciencia en la vida...

08.28.12
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Trick of the Trade: Oral naloxone for opioid-induced constipation


Opioids are amazingly effective for pain control. Patients on chronic opioids, however, often struggle with constipation. These patients may fail supportive treatment with enemas and laxatives.

Trick of the Trade:
Oral naloxone

Interestingly, there are minimal systemic effects with oral naloxone. So, constipation can be directly targeted without causing systemic opioid withdrawal. Published case series reports show a variable range of therapeutic doses, ranging from 0.1-20 mg of oral naloxone. One series quoted no effectiveness under 1.5 mg. Generally 2 mg PO is a good starting point. Then titrate up slowly to achieve the laxative effect to minimize any systemic absorption.

FYI, you need to use the IV preparation, because no PO formulation exists.

Alternatively per Bryan Hayes (@PharmERToxGuy), you can also use methylnaltrexone, which also is a mu-receptor antagonist. It is dosed 8-12 mg (0.15 mg/kg) subcutaneously.

Thanks to Dr. Graham Walker (Kaiser San Francisco) and Sarah Burkart (PA at Univ of Cincinnati) for sharing this great tip!


Reference
Holzer P. Non-analgesic effects of opioids: Management of opioid-induced constipation by peripheral opioid receptor antagonists: prevention or withdrawal? Curr Pharm Des. 2012 Jun 28. [Epub ahead of print] Pubmed

Leppert W. The role of opioid receptor antagonists in the treatment of opioid-induced constipation: a review. Adv Ther. 2010 Oct;27(10):714-30. Pubmed .

Meissner W, Schmidt U, Hartmann M, Kath R, Reinhart K. Oral naloxone reverses opioid-associated constipation. Pain. 2000 Jan;84(1):105-9. Pubmed .


08.28.12
by

Trick of the Trade: Oral naloxone for opioid-induced constipation


Opioids are amazingly effective for pain control. Patients on chronic opioids, however, often struggle with constipation. These patients may fail supportive treatment with enemas and laxatives.

Trick of the Trade:
Oral naloxone

Interestingly, there are minimal systemic effects with oral naloxone. So, constipation can be directly targeted without causing systemic opioid withdrawal. Published case series reports show a variable range of therapeutic doses, ranging from 0.1-20 mg of oral naloxone. One series quoted no effectiveness under 1.5 mg. Generally 2 mg PO is a good starting point. Then titrate up slowly to achieve the laxative effect to minimize any systemic absorption.

FYI, you need to use the IV preparation, because no PO formulation exists.

Alternatively per Bryan Hayes (@PharmERToxGuy), you can also use methylnaltrexone, which also is a mu-receptor antagonist. It is dosed 8-12 mg (0.15 mg/kg) subcutaneously.

Thanks to Dr. Graham Walker (Kaiser San Francisco) and Sarah Burkart (PA at Univ of Cincinnati) for sharing this great tip!


Reference
Holzer P. Non-analgesic effects of opioids: Management of opioid-induced constipation by peripheral opioid receptor antagonists: prevention or withdrawal? Curr Pharm Des. 2012 Jun 28. [Epub ahead of print] Pubmed

Leppert W. The role of opioid receptor antagonists in the treatment of opioid-induced constipation: a review. Adv Ther. 2010 Oct;27(10):714-30. Pubmed .

Meissner W, Schmidt U, Hartmann M, Kath R, Reinhart K. Oral naloxone reverses opioid-associated constipation. Pain. 2000 Jan;84(1):105-9. Pubmed .


08.28.12
by

Hacking Education

Oh, this is good.

Robert Cooney (@EMEducation) of Better in Emergency Medicine recently featured this TEDx talk by Scott Young in a post called ‘Hack Your Education‘.

Scott studied business for pragmatic reasons, but was always interested in Computer Science. Through the use of cognitive science principles and effective productivity techniques, in combination with free online courses, Scott gave this talk while well on the way to completing the equivalent of a four year computer science degree from MIT in just one year. That’s right, just one year.

http://www.youtube.com/watch?v=piSLobJfZ3c

Some lessons for us all:

  • traditional ‘go to the lecture’ teaching is inefficient -- there’s the commuting times, being stuffed in a crowded noisy lecture hall at inconvenient times, and the limited opportunity to interact with teachers. Lectures suck up time, can’t be revisited and the real learning happens afterwards when the student has to ‘nut out’ the things they didn’t understand for themselves.
  • Scott did his assignments question by question, checking the model answer after every question. Much like the LITFL case-based Q&A approach, this active ‘test yourself then get instant feedback’ is critical to reinforcing learning.
  • Scott watched and listened to lectures at one-and-a-half speed. I must admit I tend to do this for podcasts too, unless there is real fast talking. Scott claims this approach alone allowed him to cover 4 months of lectures in just 2 days!
  • If you want to be productive, analyse where you REALLY spend your time -- a time log will dispel the myths we all have about what we do with our time.
  • Learning is lifelong -- by hacking education we can make it easier for ourselves during school and after school.

Go on, get hacking!

 

The post Hacking Education appeared first on iTeachEM.

08.28.12
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From BURP to BILP: backwards internal laryngeal pressure

A burns patient whose tracheal tube was accidentally dislodged and ended up placed in the oesophagus on day 2 of his ICU stay continued to spontaneously ventilate and maintain saturations on a midazolam infusion. The oesophageal tube was left in during laryngoscopy (after propofol but no muscle relaxant due to anticipated difficult airway) which revealed a cormack-lehane grade 3 view. The operator’s hand which was holding a bougie rested on the oesophageal tube, which displaced it backwards. This resulted in backwards displacement of the larynx and improved the glottic view to 2b, facilitating intubation.

The discovery of this ‘backwards internal laryngeal pressure’ manoeuvre led the authors to make the recommendation that during difficult intubation an inadvertently placed oesophageal tube should be left in place to allow a BILP manouevre, but removed if it impedes the passage of the tracheal tube.

I love anything that might improve success rates of critical procedures and this one could conceivably come in handy. I can just see Minh Le Cong inventing a transoesophageal posterior laryngal retractor for under 50 bucks…

The use of "Internal Laryngeal Pressure" to improve the laryngeal view following inadvertent oesophageal intubation in a patient with difficult airway
Anaesth Intensive Care. 2012 Jul;40(4):736-7

08.28.12
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New 3D clinical simulation learning modules for nurses.

The Australian Nursing Federation is offering a series of online 3-D clinical simulations for nurses.

Federal Education Officer Jodie Davis said the new website, launched today demonstrates the ANF's ongoing commitment to the continuing education of Australia's nurses and midwives.

"This innovative website offers 3D simulated learning for clinical procedures," Ms Davis explained.
"Each module teaches a different procedure through an interactive simulation, accompanied by a step-by-step text with hyperlinks, a video demonstration, a 3D model of the anatomy encountered during the procedure and a quiz.

"The simulation is also available in test mode so the nurse or midwife can check their competence.
"Scores and time taken to complete each module is stored in a logbook on the website for easy transference to the CPE professional development portfolio."

There are a total of 32 modules including:

  • Venous Cannulation
  • Perform and interpret an ECG
  • Assist with minor surgical procedures
  • Paediatric assessment (infant)
  • Perform suture removal
  • Administer nebuliser treatment and assess peakflow
  • Perform capillary puncture and haematology testing
  • Urinary Bladder catheterisation
  • Nasogastric tube
  • Administer intramuscular injections
  • Electrocardiogram (ECG) – 12 Lead

On completion of each module you receive a Simulation Summary Report which can be printed out.

Prices fro ANF members is $10 per module, which gives you access to the module for one month.
Non-members pay $15.

You can register and access the modules here.

If you cant see the player above, here is a link to the video.

08.28.12
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Feel inside (and stuff like that).

The always-make-me-smile Flight of the Conchords have released a single to raise money for the New Zealand children's foundation: www.curekids.org.nz

They need to raise a million and a hundred and ten and twenty-one dollars.

At Cure Kids, our purpose is simple. Every single day, we're driven to find cures for the life-threatening illnesses that affect many of our children.

Approximately one child in 30 is affected by a genetic malformation; that's an average of roughly one in every classroom. We're searching for cures for, among others, childhood leukaemia and other cancers, heart diseases, cystic fibrosis, Sudden Infant Death Syndrome, Type 1 diabetes and asthma. These cruel conditions and diseases mean children are often robbed of a normal childhood and have to learn far too early in life how to fight to survive.

Actually, its more like the kids wrote the song, which you can see performed at the end of the clip by a whole bunch of NZ artists including: Dave Dobbyn, Brooke Fraser, Boh Runga, Sam Scott, Luke Buda, Savage, Young Sid, Tyree, Deach, PNC, Zowie, Ruby Frost, Kids of 88, Rikki Morris, Moana Maniapoto, Nathan King, Maitereya, Victoria Girling-Butcher, Elizabeth Marvelly, Peter Urlich and Cherie Mathieson.

If you cant see the player above, here is a link to the video.

08.28.12
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the moron list

Dear Mr/Mrs John/Jane Q. Public:

******A HANGOVER IS NOT AN EMERGENCY*****

REPEAT

******A HANGOVER IS NOT AN EMERGENCY*****

Your tummy upset is not our problem. I don't care if you literally puke your guts out. Do not come to your local emergency room. If you do, here is what will happen:

We will talk about you. The staff will talk amongst themselves about what an idiot you are.

If you take an ambulance into the ER for this you will go to the top of the moron list that we keep in a drawer in triage.

*****THAT IS ALL*****

Go about your business. Nothing to see here.

emergency room nurse
08.28.12
by

the moron list

Dear Mr/Mrs John/Jane Q. Public:

******A HANGOVER IS NOT AN EMERGENCY*****

REPEAT

******A HANGOVER IS NOT AN EMERGENCY*****

Your tummy upset is not our problem. I don't care if you literally puke your guts out. Do not come to your local emergency room. If you do, here is what will happen:

We will talk about you. The staff will talk amongst themselves about what an idiot you are.

If you take an ambulance into the ER for this you will go to the top of the moron list that we keep in a drawer in triage.

*****THAT IS ALL*****

Go about your business. Nothing to see here.

emergency room nurse
08.28.12
by

the moron list

Dear Mr/Mrs John/Jane Q. Public:

******A HANGOVER IS NOT AN EMERGENCY*****

REPEAT

******A HANGOVER IS NOT AN EMERGENCY*****

Your tummy upset is not our problem. I don't care if you literally puke your guts out. Do not come to your local emergency room. If you do, here is what will happen:

We will talk about you. The staff will talk amongst themselves about what an idiot you are.

If you take an ambulance into the ER for this you will go to the top of the moron list that we keep in a drawer in triage.

*****THAT IS ALL*****

Go about your business. Nothing to see here.

emergency room nurse
08.28.12
by

Visual Aid Questions in Emergency Medicine

Visual aid questions (VAQs) are employed widely in medical and other biological science examinations as these environments have a wealth of visually analysed material in daily practice. VAQs comprise one of the three sections of the ACEM Fellowship written examination, in which ACEM examiners assess the candidate's competence to:

  1. Recognise and describe visual data encountered in Emergency Medicine practice
  2. Synthesise relevant and negative features of this data
  3. Interpret the data within a specific clinical context.
  4. Display knowledge consistent with safe contemporary Emergency Medicine practice in  questions relating to the data.
  5. Consistently and adequately interpret a range of medical data in a limited time period

The ACEM format is eight questions in 80 minutes, no reading time, with a typical breakdown being two ECGs, two investigations, two radiology and two clinical images. This section has historically demonstrated lower overall pass rates by candidates than the other two written sections. (MCQs and Short Answer Questions) Several reasons contribute to this, but I believe the most important is insufficient practice (to time) of the typical range of material, leading to poor time management and answer structure when under fire on the day. In an attempt to demystify the VAQ, especially for those of you approaching the lower slopes of Mt FACEM, I'll firstly outline how VAQs are created, then try the process with some new images, and finally list my tips to help improve your success at this domain of the quiz.

 Creation

An ACEM committee of experienced FACEMs source original props from their daily work in a wide range of Australasian EDs. One will usually generate a draft question for the prop, then disseminate to the others for editing/changes/comments to create a final draft. All VAQs have the initial question "Describe and interpret"…, but less complex props will require a second question, either specific such as "Outline your further investigation", or broader "Outline your management" to fully utilise the 10 minute timeframe. (In the most recent VAQ examination 2012.2, there were three of the eight questions with just "Describe and interpret", and five with an additional second question.) After reaching final draft stage, that question is road tested by ACEM examiners who haven't seen it before, and after considering their feedback, the question is finalised and banked for use in a future exam.

Let's try this ourselves - say we wish to create an orthopaedic VAQ on the topic of knee fracture. We have three knee Xrays available and our question stem is: "A 74 year old woman is brought to your ED with a painful knee after a mechanical fall at her home. There are no other injuries, but she is unable to bear weight on it so an Xray is performed." Decide which image is most suitable for use in the ACEM exam (that is, at a level of difficulty/complexity suitable for an emergency physician) and whether it would be  "D + I" for 100% of the ten minutes, or require an additional question. I'll put my thoughts on their merits as well as a description for each.

I think the best VAQs are those which have a visual prop complex enough to not require a second question, and which most reflect either clinically important or frequently encountered material in the ED. So I'm not keen on rarities or "spot the lesion" type props with no differentials to consider, and as an ACEM examiner, I find it easier to set pass criteria for a one part (100% D+I) question

Image 1 is an AP Xray of the left knee demonstrating a lateral tibial plateau fracture with obvious depression of the tibial plateau cortex and increased lateral tibial metaphyseal opacification. There is no obvious cortical breach or deformity, nor abnormal soft tissue features.

Image 2 is another AP Xray of the left knee; it shows an impacted distal femoral facture at the insertion site of the femoral component of a total knee replacement. The tibia is angulated laterally mildly relative to the femur and the prosthesis appears enlocated, but this requires verification with a lateral view. There is popliteal vascular calcification and the bones are osteopenic generally.

Image 3 is an AP Xray of the right knee that shows increased tibial metaphyseal opacification laterally, minimal depression of the lateral tibial plateau, and a slightly unclear cortical margin of the tibia in this area compared with the medial side. The soft tissues appear to show a displaced fat pad over the distal femur laterally which would suggest a haemarthrosis and further support the diagnosis of a relatively undisplaced lateral tibial plateau fracture.

I would choose the first and second images to use as they have more content to assess and describe, and greater clinical significance. The first would require a second question as it is an obvious fracture without xray complexity, perhaps a 50/50 time split. Either treatment or further investigation would be appropriate as a second question. Xray 2 might be OK as a 100% question. The third image on its own has subtle abnormalities that I think would be hard for the examiner to set strict pass criteria for, and which might be missed if a candidate was rushing to make up time. If used the question would be enhanced greatly by utilising this lateral view which doesn’t further demonstrate the tibial plateau fracture, but does show the associated lipohaemarthrosis. (and a fabella)

Tips for success

  1. Practise to time - this appears obvious but repeatedly doing VAQs to the 10 minute limit is vital. Performance will improve and gradually evolve to a concise style utilising a  "dot point"/ bulleted format, with highlighting of important positive and negative elements. Don't rewrite question or do "key points" at the start of your answer.
  2. Certain types of props are used in every exam, for example ECGs, so becoming adept at ECG interpretation will clearly serve you well. Similarly with common imaging (CXR, CT Brain) and investigations (ABGs and electrolytes) Many of these VAQs are completely predictable and you can be ready to nail them. ECGs lend themselves well to a template style approach, here's an example: LITFL ECG template
  3. Create your own and share with colleagues - it's also a good, fun way to study and revise topics.
  4. Do VAQs from previous ACEM examinations; I suggest you focus mainly on those from the last few years.
  5. Show your questions and answers to ACEM examiners or experienced FACEMs and listen to their feedback
  6. Write legibly. Write legibly. Write legibly!
  7. Be very careful with ABG and other calculations, its very easy to get these wrong when you're in a hurry, so take a few extra seconds to check them twice
  8. At least once before the exam, do eight VAQs to time and get them marked, its very different to one or two at a time, and a real test of your technique.
  9. Always move on at the end of each allotted 10 minutes as its virtually impossible to make up time once you're behind the clock. If however this still happens, put all the information you would have expanded on in your last question as a bulleted outline so the examiner will at least see the scope of your intended answer - it might still be enough for a pass! This is much better than writing an unfinished answer for the, say 6 minutes, that was all you the time you had remaining.
If you have other tried and true approaches I’d love to hear from you.

 

 

 

 

 

 

 

 

08.28.12
by

Fetal Lead Exposure from Ayurvedic Medications

3.5 out of 5 stars

Lead Poisoning in Pregnant Women Who Used Ayurvedic Medications from India -- New York City, 2011-2012. MMWR 2012 Aug 24;61:641-646.

Full Text

Fetal lead exposures carries increased risk of low birth weight, developmental delay, cognitive impairment, behavioral abnormalities, and miscarriage. Some traditional Ayurvedic medications from India -- especially those of the “rasa shastra” type prepared with metals or mineral -- have been found to contain lead, mercury, and/or arsenic. The CDC recommends that all pregnant women who use traditional remedies such as ayurvedic medications be tested for lead exposure.

This case series describes 6 asymptomatic pregnant women who had elevated lead levels (up to 64 ?g/dL) on mandatory prenatal screening. All were using Ayurvedic medications made in India.

The discussion points out that foreign-born pregnant women might have elevated lead levels not only from current exposure, but also because the fetus’s need for calcium to support bone growth might release lead in the mother’s bones from previous use.

The authors recommend that health providers should:

  1. ask patients about use of nonprescription medications and supplements, including Ayurvedic preparations
  2. advise patients to stop using such products
  3. consider patients who use or have used these products for lead and other heavy metals

External link: Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women (CDC)

 

08.28.12
by

Feel Inside (And Stuff Like That)

We all want to help sick kids, eh.

This is how Flight of the Conchords and a host of other Kiwi musical artists are trying to do it.

It’s a unique experiment in crowd sourcing.

It’s magic.

http://www.youtube.com/watch?v=PQ4cRW8gLpw

Hat tip to @dreapadoir F.UCEM.

You can buy the charity single here.

 

The post Feel Inside (And Stuff Like That) appeared first on Life in the Fast Lane medical education blog.

08.28.12
by

Pregnant and metabolic acidosis?

aka Metabolic Muddle 008

You are asked to review a pregnant patient (30 weeks gestation) who has been diagnosed with pneumonia. The referring doctor is concerned that she has a metabolic acidosis. She is currently receiving high flow oxygen with an FiO2 of 0.5.

This is her arterial blood gas:

Questions

Q1. Describe and interpret the A-a gradient.

Description

  • A-a gradient (mmHg) = PAO2 – PaO2
  • Using the alveolar gas equation, PAO2 = PiO2 – PaCO2/R; where are is the respiratory quotient, typically with a value of 0.8
  • PiO2 = FiO2 x (PB – PH20) = 0.5 x (760 -47) = 357 mmHg; where FiO2 is the fraction of inspirated oxygen, PB is barometric pressure and PH20 is the stand vapour pressure of water. In other words, how much oxygen is in the lungs depends on the percentage of oxygen being breathed in, the atmospheric pressure and how much gas is displaced by the inspired gas being saturated with water.
  • PaCO2/R = 29/0.8 = 36 mmHg
  • So, PAO2 = PiO2 – PaCO2/R = 357 mmHg – 36 mmHg = 321 mmHg
  • And finally the A-gradient is PAO2 – PaO2 = 321 – 123 = 198 mmHg

Interpretation

  • The A-a gradient is high. The normal value varies with age and FiO2 as follows:
    -- At FiO2 0.21: 7 mmHg in young, 14 mmHg in elderly
    -- At FiO2 1.0: 31 mmHg in young, 56 mmHg in elderly
  • The high A-gradient is due to her pneumonia, with the underlying pathophysiological mechanisms being V/Q mismatch and/ or shunt.

In a written exam it is important to perform the full calculation when describing the A-a gradient. On the fly a useful rule of thumb is this:

The expected PaO2 = FiO2 x 500

In this case the expected PaO2 = 250 mmHg, which is substantially higher than the measured PaO2 of 123 mmHg, also indicating a high A-a gradient.

Finally, another rule of thumb: to estimate the normal A-a gradient you can use the same equation we use for calculating ETT size in children:

Approximate expected A-a gradient = age/4 + 4

Q2. Describe and interpret the metabolic parameters on the ABG.

Description

  • pH 7.42 is normal, but leans towards an alkalemia for the purpose of further acid base interpretation.
  • PCO2 29 mmHg indicates a respiratory alkalosis
  • HCO3 20 mmol/L indicates appropriate metabolic compensation for the respiratory alkalosis, not primary metabolic acidosis. A drop of ~10 mmHg in PaCO2 from normal (40 mmHg), if there is appropriate compensation, will lead to a fall in HCO3 of 2 mmol/L acutely, or 5 mmol/L chronically from the normal concentration (25 mmol/L)
  • Mild hyponatremia, hypokalemia, hypergylcemia
  • Anaemia (Hb 84 g/L)

Interpretation

  • The apparent metabolic acidosis is actually a compensated respiratory alkalosis, which is normal in the third trimester of pregnancy. Progesterone induces a respiratory alkalosis and the kidney compensates by excreting HCO3.
  • The electrolyte abnormalities may have various causes including SIADH due to pneumonia, dehydration, fluid administration, etc, etc.
  • Mild hyperglycemia is not unexpected given the relatively insulin resistant state of the third trimester of pregnancy and the stress of an inter-current illness.
  • Relative anaemia is expected in pregnancy as the 30-40% expansion in plasma volume exceeds the 20-25 % increase in red cell mass that occurs in pregnancy. However, an Hb <105 g/L in the third trimester suggests other causes may be at play, usually iron deficiency.

References and Links

Lifeinthefastlane.com

Social Media and Web Resources

The post Pregnant and metabolic acidosis? appeared first on Life in the Fast Lane medical education blog.

08.27.12
by

Tolerance Level = Zero

Tweet I’m not sure if I’m alone in this feeling but when it is 4am and I am by myself after the PA has left, my tolerance level for bullshit, whininess, complaining, and unreasonable demands drops to zero. During the day I can negotiate with drug seekers, crybabies, and people suffering from Entitlement Disorder ™ [...]
08.27.12
by

Hyperkalemia episode fixed on the EM Basic App

Hey everybody

Just a quick note to say that I just fixed an issue with the hyperkalemia episode on the EM Basic app.  I goofed and the way I posted the episode was causing it to come up in the app as a “text post” without the episode audio.  It is fixed now and should be working- let me know if you are having any other issues with the app.

Steve


08.27.12
by

All Together Now

Some of you may have noticed an upgrade to The EMBER Project’s Facebook page. The rapidly changing internet landscape opens up incredible opportunities for emergency physicians to learn and share online. It also presents challenges on how to stay up to date effectively in a wired world. The Facebook page is rapidly becoming the solution by acting as a nexus for The EMBER Project’s various social media platforms.

Currently The EMBER Project’s Facebook page is the central repository and distribution site for updates from our Blog as well as feeds from Twitter, Instagram, Pinterest, and Evernote. Each of these platforms offers a different learning opportunity; a chance to share information in exciting new ways that make emergency medicine online more interesting than ever before.

Now, when you go to our Facebook page you will continue to see all blog posts and other updates on the timeline, but you will also see links to each of the various feeds (Pinterest, Twitter, Instagram, Evernote). If you LIKE us on the Facebook page you’ll get regular updates from our various platforms all in one place.

The EMBER Project is almost six months old and continues to evolve; I’m excited to explore the various possibilities of our new updated online presence.

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Filed under: Uncategorized
08.27.12
by

The iTeachEM Podcast

Well, it’s about time…the new iTeachEM Podcast is being developed. This podcast, the replacement for EMRAP-Educators Edition, promises to be the premier medical education podcast in emergency medicine. Although much of the content will be focused on the specialty of emergency medicine, the podcast will cover content pertinent to all aspects of medical education and faculty development.

Please send us your suggestions for topics. Content is being created at this very moment, and we hope to have the very first episode posted very soon. Stay tuned!

Rob Rogers and Chris Nickson

The iTeachEM crew

 

The post The iTeachEM Podcast appeared first on iTeachEM.

08.27.12
by

Thinking About Thinking

The Gist:  Clinical reasoning in the EM setting is different than other arenas as one must often make life and death decisions (and actions) with limited information and even less time.  Our patients are often undifferentiated and nearly any ailment exists as a possibility.  Furthermore, EPs are constantly juggling multiple patients and responsibilities.  As a result, cognitive errors are common and play a role in clinical decision making (although this also applies to all fields of medicine).  Thinking about thinking or, "metacognition," may help reduce these cognitive errors to allow Emergency Physicians (EPs) to improve diagnostic and treatment decision making.   

The case that made me care about cognitive errors:  A 40-something year old patient presented to the hospital with nausea, vomiting, and epigastric pain stating "this feels a lot like my pancreatitis."  The patient had a history of pancreatitis and helicobacter pylori in addition to the all-American trio:  diabetes, hypertension, and hypercholesterolemia.  The labs, work up, and patient all seemed to proclaim pancreatitis.  Unfortunately, the patient bounced back within a day in heart failure, status-post massive MI.  Ever since, I've been exceptionally wary of diabetics with nausea and vomiting and garnered a fascination with the thinking of an EP.

In medical school, we're overtly taught clinical reasoning through data mining in the form of history, physical exam, and diagnostic testing.  I suppose we're subtly and indirectly taught to think about the way we integrate and assimilate this data into a coherent picture of the patient and an accurate diagnosis.  We subconsciously use heuristics, cognitive short cuts, to inform clinical gestalt.  My formal medical education, however, did not include any discussion of cognitive bias or meta-cognition until a resident at a program I rotated at gave a brief presentation on metacognition.
  • Apparently, we can reduce errors if we step back for a moment and think:  What doesn't fit? What have I failed to consider (perhaps a zebra? or a different horse?)?  What biases may be present?  What is leading me to think that this patient has X?
This is so important that I wanted to disseminate this information to help others who strive to be excellent thinkers and swell clinicians.

Basic systems of thinking.  Between which we have the capability to toggle, which we should probably exercise more often. Check out this lecture.
  • "System 1" or "Fast":  This is the instinct, intuitive, adaptive, associative, quick thinking.  We use this system when we say, "this patient just looks sick" or "I have this gut feeling the patient has ______."  Caution: medical students and trainees should really not rely on this type of thinking although it is often key in EM (think clinical gestalt)
  • "System 2" or "Analytic":  This is a slower process of thinking which is more deliberate and analytic.
Common EM thinking patterns:
  • Hypothetico-Deductive Model:  One of the most common cognitive pathways used in medicine - useful in non-critical situations, as algorithms such as ATLS and ACLS tend to dominate in the more critical circumstances.  
    • Main steps:  Generation, Evaluation, Refinement, Verification.  Errors can be present in any step.  
    • Error in Generation - failure to consider a potential diagnosis (influenced by disease prevalence, atypical presentations, etc).  
    • Error in Evaluation - problems in gathering data, interpreting and assimilating the data, and putting the data in the proper context.
    • Error in Verification - failure to ensure that the final diagnosis fits with the clinical picture and established data/workup.
  • Pattern Recognition Model:  This dominates when an experienced clinician uses clinical gestalt to inform the diagnosis rather than generating a complete differential diagnosis (and thereby prone to error for failing to consider alternative diagnoses).
  • Rule Out Worse Case Scenario Model:  Some clinicians employ this most of the time and others tend to apply it when particularly high-risk diagnoses are on the table.  This method of reasoning is expensive and exposes the patient to excess harms through extensive investigations.
Why may the ED be a breeding ground for cognitive error?
  • High levels of diagnostic uncertainty
  • High decision density and cognitive load
  • High levels of activity
  • Inexperience of some providers (and students)
  • Interruptions and distractions
  • Shift changes
  • Many of these, integrated, produce fatigue
  • These errors occur in every facet of medicine but in EM, there is a certain expectation that EPs not miss the badness (or anything).
The papers to read (note:  Dr. Patrick Croskerry is a world-reknowned expert in this arena.  If you're looking for even more to read, check out his plethora of articles.  Also, he has several free talks on freeemergencytalks.net, which can be converted to podcasts within iTunes)  


Life in the Fast Lane provides some succinct case-based insight into cognitive errors with To Err is Human 1 and To Err is Human 2


Achieving quality in clinical decision making: cognitive strategies and detection of bias - Croskerry


This article, also by Croskerry has a rather complete list of cognitive errors in the tables embedded in the free text article.



Other References:
Jepson, Zak. University of Massachusetts.  Medical Student Lecture. August 15, 2012.
08.27.12
by

Thinking About Thinking

The Gist:  Clinical reasoning in the EM setting is different than other arenas as one must often make life and death decisions (and actions) with limited information and even less time.  Our patients are often undifferentiated and nearly any ailment exists as a possibility.  Furthermore, EPs are constantly juggling multiple patients and responsibilities.  As a result, cognitive errors are common and play a role in clinical decision making (although this also applies to all fields of medicine).  Thinking about thinking or, "metacognition," may help reduce these cognitive errors to allow Emergency Physicians (EPs) to improve diagnostic and treatment decision making.   

The case that made me care about cognitive errors:  A 40-something year old patient presented to the hospital with nausea, vomiting, and epigastric pain stating "this feels a lot like my pancreatitis."  The patient had a history of pancreatitis and helicobacter pylori in addition to the all-American trio:  diabetes, hypertension, and hypercholesterolemia.  The labs, work up, and patient all seemed to proclaim pancreatitis.  Unfortunately, the patient bounced back within a day in heart failure, status-post massive MI.  Ever since, I've been exceptionally wary of diabetics with nausea and vomiting and garnered a fascination with the thinking of an EP.

In medical school, we're overtly taught clinical reasoning through data mining in the form of history, physical exam, and diagnostic testing.  I suppose we're subtly and indirectly taught to think about the way we integrate and assimilate this data into a coherent picture of the patient and an accurate diagnosis.  We subconsciously use heuristics, cognitive short cuts, to inform clinical gestalt.  My formal medical education, however, did not include any discussion of cognitive bias or meta-cognition until a resident at a program I rotated at gave a brief presentation on metacognition.
  • Apparently, we can reduce errors if we step back for a moment and think:  What doesn't fit? What have I failed to consider (perhaps a zebra? or a different horse?)?  What biases may be present?  What is leading me to think that this patient has X?
This is so important that I wanted to disseminate this information to help others who strive to be excellent thinkers and swell clinicians.

Basic systems of thinking.  Between which we have the capability to toggle, which we should probably exercise more often. Check out this lecture.
  • "System 1" or "Fast":  This is the instinct, intuitive, adaptive, associative, quick thinking.  We use this system when we say, "this patient just looks sick" or "I have this gut feeling the patient has ______."  Caution: medical students and trainees should really not rely on this type of thinking although it is often key in EM (think clinical gestalt)
  • "System 2" or "Analytic":  This is a slower process of thinking which is more deliberate and analytic.
Common EM thinking patterns:
  • Hypothetico-Deductive Model:  One of the most common cognitive pathways used in medicine - useful in non-critical situations, as algorithms such as ATLS and ACLS tend to dominate in the more critical circumstances.  
    • Main steps:  Generation, Evaluation, Refinement, Verification.  Errors can be present in any step.  
    • Error in Generation - failure to consider a potential diagnosis (influenced by disease prevalence, atypical presentations, etc).  
    • Error in Evaluation - problems in gathering data, interpreting and assimilating the data, and putting the data in the proper context.
    • Error in Verification - failure to ensure that the final diagnosis fits with the clinical picture and established data/workup.
  • Pattern Recognition Model:  This dominates when an experienced clinician uses clinical gestalt to inform the diagnosis rather than generating a complete differential diagnosis (and thereby prone to error for failing to consider alternative diagnoses).
  • Rule Out Worse Case Scenario Model:  Some clinicians employ this most of the time and others tend to apply it when particularly high-risk diagnoses are on the table.  This method of reasoning is expensive and exposes the patient to excess harms through extensive investigations.
Why may the ED be a breeding ground for cognitive error?
  • High levels of diagnostic uncertainty
  • High decision density and cognitive load
  • High levels of activity
  • Inexperience of some providers (and students)
  • Interruptions and distractions
  • Shift changes
  • Many of these, integrated, produce fatigue
  • These errors occur in every facet of medicine but in EM, there is a certain expectation that EPs not miss the badness (or anything).
The papers to read (note:  Dr. Patrick Croskerry is a world-reknowned expert in this arena.  If you're looking for even more to read, check out his plethora of articles.  Also, he has several free talks on freeemergencytalks.net, which can be converted to podcasts within iTunes)  


Life in the Fast Lane provides some succinct case-based insight into cognitive errors with To Err is Human 1 and To Err is Human 2


Achieving quality in clinical decision making: cognitive strategies and detection of bias - Croskerry


This article, also by Croskerry has a rather complete list of cognitive errors in the tables embedded in the free text article.



Other References:
Jepson, Zak. University of Massachusetts.  Medical Student Lecture. August 15, 2012.
08.27.12
by

Thinking About Thinking

The Gist:  Clinical reasoning in the EM setting is different than other arenas as one must often make decisions with limited information and even less time.  Our patients are often undifferentiated and nearly any ailment exists as a possibility.  Furthermore, EPs are constantly juggling multiple patients and responsibilities.  As a result, cognitive errors are common and play a role in clinical decision making (although this also applies to all fields of medicine).  Thinking about thinking or, "metacognition," may help reduce these cognitive errors to allow Emergency Physicians (EPs) to improve diagnostic and treatment decision making.   

The case that made me care about cognitive errors:  A 40-something year old patient presents to the hospital with nausea, vomiting, and epigastric pain stating "this feels a lot like my pancreatitis."  The patient has a history of pancreatitis and helicobacter pylori in addition to the all-American trio:  diabetes, hypertension, and hypercholesterolemia.  The labs, work up, and patient all seemed to proclaim pancreatitis.  Unfortunately, the patient bounced back within a day in heart failure, status-post massive MI.  Ever since, I've been exceptionally wary of diabetics with nausea and vomiting and garnered a fascination with the thinking of an EP.

In medical school, we're overtly taught clinical reasoning through data mining in the form of history, physical exam, and diagnostic testing.  I suppose we're subtly and indirectly taught to think about the way we integrate and assimilate this data into a coherent picture of the patient and an accurate diagnosis.  We subconsciously use heuristics, cognitive short cuts, to inform clinical gestalt.  My formal medical education, however, did not include any discussion of cognitive bias or meta-cognition until a resident at a program I rotated at gave a brief presentation on metacognition.
  • Apparently, we can reduce errors if we step back for a moment and think:  What doesn't fit? What have I failed to consider (perhaps a zebra? or a different horse?)?  What biases may be present?  What is leading me to think that this patient has X?
This is so important that I wanted to disseminate this information to help others who strive to be excellent thinkers and swell clinicians.

Basic systems of thinking.  Between which we have the capability to toggle, which we should probably exercise more often. Check out this lecture.
  • "System 1" or "Fast":  This is the instinct, intuitive, adaptive, associative, quick thinking.  We use this system when we say, "this patient just looks sick" or "I have this gut feeling the patient has ______."  Caution: medical students and trainees should really not rely on this type of thinking although it is often key in EM (think clinical gestalt)
  • "System 2" or "Analytic":  This is a slower process of thinking which is more deliberate and analytic.
Common EM thinking patterns:
  • Hypothetico-Deductive Model:  One of the most common cognitive pathways used in medicine - useful in non-critical situations, as algorithms such as ATLS and ACLS tend to dominate in the more critical circumstances.  
    • Main steps:  Generation, Evaluation, Refinement, Verification.  Errors can be present in any step.  
    • Error in Generation - failure to consider a potential diagnosis (influenced by disease prevalence, atypical presentations, etc).  
    • Error in Evaluation - problems in gathering data, interpreting and assimilating the data, and putting the data in the proper context.
    • Error in Verification - failure to ensure that the final diagnosis fits with the clinical picture and established data/workup.
  • Pattern Recognition Model:  This dominates when an experienced clinician uses clinical gestalt to inform the diagnosis rather than generating a complete differential diagnosis (and thereby prone to error for failing to consider alternative diagnoses).
  • Rule Out Worse Case Scenario Model:  Some clinicians employ this most of the time and others tend to apply it when particularly high-risk diagnoses are on the table.  This method of reasoning is expensive and exposes the patient to excess harms through extensive investigations.
The papers to read (note:  Dr. Patrick Croskerry is a world-reknowned expert in this arena.  If you're looking for even more to read, check out his plethora of articles.  Also, he has several free talks on freeemergencytalks.net, which can be converted to podcasts within iTunes)  


Life in the Fast Lane provides some succinct case-based insight into cognitive errors with To Err is Human 1 and To Err is Human 2


Achieving quality in clinical decision making: cognitive strategies and detection of bias - Croskerry


This article, also by Croskerry has a rather complete list of cognitive errors in the tables embedded in the free text article.



Next up:  Anchoring, Triage, and Confirmation...Examples of Cognitive Bias/Error and Solutions