Lecture: Acid Base Disorders (Sorry, no ECGs!) — 50 minutes
Prison Inmates: Smarter than Patients
Increased Newborn Narcotic Addicts
Increased Newborn Narcotic Addicts:
Frightening, depressing, but not all that surprising. JAMA article here. I can't clearly tell from either article whether these women are:
- on chronic narcotics for chronic pain and then get pregnant
- in methadone programs and then get pregnant
- abusing narcotics and pregnant
Because I honestly can't see a whole bunch of OBs or non-OBs prescribing narcotics to pregnant women. I think I have once, and it was a pregnant woman with a nasty ankle fracture.
I certainly now see an epidemic -- depending on the shift, honestly up to 10% of my patients are young people with chronic complaints on chronic narcotics. I'd have the say the most common (and most frustrating) is chronic abdominal pain. It's usually but not always young, child-bearing-aged women, who -- no surprise here -- probably get pregnant at some point.
And, in the "These Two Reporters Should Have Filed Their Stories Together" category comes this piece from the NYT: E.R. Doctors Face Quandary on Painkillers, which is again no surprise to any of us in the Emergency Medicine world, but kind of nice to at least get some public validation of our frustration (especially that no one seems to be interested in helping us solve it):
"You can be faulted for not treating a patient's pain -- it's considered the 'fifth vital sign,' " said Dr. Abhi Mehrotra, the assistant director of the emergency medicine department at the University of North Carolina Hospitals. "We have to ask a patient's pain, on a scale of 0 to 10, as well as document a reassessment of their pain after treatment." Dr. Benzoni, who is routinely rated on patient satisfaction and sometimes asked by management to explain a bad review, said that he feels at times as if he faces a no-win choice. "If you're going to criticize me for not giving out narcotics, and you never praise me for correctly identifying a drug-seeker," he said, "then I'm going to give out narcotics."
Far be it from me to point fingers, but the whole JCAHO (sorry, "The Joint Commission") "pain must be reassessed and is now a vital sign" bit probably got us in this mess. I'm all for treating people's pain -- easing suffering is part of why I went into medicine, and particularly Emergency Medicine -- but it's become a total quagmire.
Becoming an Expert with Deliberate Practice
I've recently discovered a new blog called Expert Enough, by a guy called Corbett Barr. It's a great site with lots of articles on educational and learning theories. One recent post stood out to me, and that was the post on Deliberate Practice, as I think it contains a lot of good advice for people studying for Fellowship Exams.
In the article, Corbett discusses some research which shows that deliberate practice which you are motivated to do and intentionally concentrate on, which takes into account your pre-existing knowledge and current skill level, which you repeatedly perform and receive immediate feedback on will lead to better results. Sounds like common sense right? The point is that simple practice is not enough. Thos who have spent hours at their desks sweating over VAQ and SAQ answers will recognise that you will improve faster and get better results if you apply these principles.
There's some other great articles on how shortcuts to becoming an expert don't really exist, and a great discussion of the much quoted 10,000 hour rule for becoming an expert (which is incidentally 40 hours a week for about 5 years - the average length of a specialty training program!)
Expert Enough is a great site, with plenty of interesting reading for those interested in becoming an expert and learning about how to learn, highly recommended.
Nephrolithiasis, Questions
1. What is your preferred pain regimen in acute renal colic? What do you like to give for home pain control?
2. When do you use ED ultrasound? If it shows hydronephrosis, how does this affect your management?
3. Do you give alpha-blockers to aid stone expulsion (tamsulosin or terazosin)?
4. Which patients do you CT? Which patients do you not CT?
Nephrolithiasis Questions Poster
From your Kiwi Correspondent Part V
Here in New Zealand, I often reflect on October 2010. You may recall that month; the fall colors were black and orange and the season was flush with fearful beards and late-inning "torture." During those pennant-winning weeks, the cauldron of Giants baseball fever hovered between bubble and froth and our community had cohesion of purpose unlike I'd seen before.
So why is it that half-a-world away (where virtually no one knows the difference between a slider and a curveball) I'm consistently reminded of the 2010 World Champs? Well, it's because the fervour of fall '10 is replicated daily in New Zealand but for a much different sport: rugby.
New Zealand has been a rugby nation since shortly after its incorporation into the Crown territories in the early19th century. The British, you see, were intent on avoiding the opulent mentality that plagued prior empires, and so chose a formidable and stoic sport to promote throughout their colonies. I don't know how successful this tactic was elsewhere, but in New Zealand the game - and its paradigm - took root.. According to Dr. Robin McConnell, in his profile Inside the All Blacks, rugby "shapes New Zealand social history and everyday life." Case in point -- it's been five months since the New Zealand national team won the Rugby World Cup on home turf, yet the All Blacks remain ubiquitous. Flags, some homemade, fly from car antennas and balconies, babies don All Black onesies, and bottles of the nation's top selling beer (Steinlager) declare "All Blacks...25 Years of Unconditional Support." Looking for front-page news? Any snippet about a present or former All Blacks player will do. Did you know that the legendary Michael Jones is helping to bring a Carl's Jr. franchise to New Zealand?
The All Blacks are a national team and rugby a national sport in New Zealand - and we really have nothing comparable in the U.S., especially in terms of unity of loyalty. Given size and diversity differences between the two countries, this may not seem a fair comparison but it nonetheless raises the question of whether this shared passion for, and culture of, rugby pervades Kiwi life beyond the pitch? And in particular, does it help make Kiwis happier and healthier?
If you ask my wife, rugby is defined as a sport played by short men wearing too short shorts around gigantic thighs. But to others, it is defined by discipline, masculinity and stoicism. It is the type of sport in which a player (true story) might insist on playing most of a match with one testicle hanging torn from his scrotum. Stories like this are common and lead one to believe that the stoicism of Kiwis is unparalleled - an observation that finds some support in medical studies on pain tolerance. It could be that rugby plays a role in the Kiwi approach to death and dying [which is?]- one that, anecdotally at least, is more accepting than that of many other countries. Additionally, the national morale may be boosted by shared enthusiasm over rugby, which, in turn, can benefit the collective welfare. Indeed if you were to ask psychologist Jonathan Haidt, author of The Righteous Mind, Kiwi rugby culture might represent a classic case of sacredness of the group - "People who worship the same idol can trust one another, work as a team and prevail over less cohesive groups."
But some argue that any such benefits are greatly overwhelmed by rugby's culture of rowdiness, drunkenness and intolerance. In fact, just as there are Kiwis who live for rugby, there are those who detest it. One blogger, in a piece entitled "NZ Rugby Morally Bereft," writes that rugby "promotes machocism, alcoholism, violence, sexism and colonialism. Rugby has also created a crippling crisis in our health sector." There is certainly truth to the first statement - the only rugby match I've ever attended hosted a highly intoxicated crowd, and I won't even attempt to describe the experience of visiting a stadium urinal. But while injuries are common, I can't believe that they are a crippling crisis. Rugby may have a higher injury rate than many other sports, and concussions (especially under-reported concussions) are of particular concern, but the rates of devastating injuries such as spinal cord injury are actually not that high. A review of nationwide injury claims related to rugby from 1999-2007 reports an average of 743 a year, most of them limb and soft-tissue injuries, with a rather (given the nature of health expenses) modest yearly cost of $5.3 million.
One of the few academics that has closely studied and written about the cultural and societal effects of Kiwi rugby is Brendan Hokowhitu, an associate dean at University of Otago. He shares a rather bleak assessment of the health effects of the sport. "I wouldn't say there is anything historically at least positive about New Zealand rugby culture and health," he wrote. "Rugby was very much part of the establishment and was as such quite oppressive of women and alterity [cultural freedom] in general."
So the All Blacks culture does have a black side. But, to reiterate, the cohesiveness of the culture certainly has positive effects regarding national identity and group mentality. New Zealanders consistently score highly in international surveys of happiness and a nationwide social survey of 8,000 Kiwis found very high levels of people feeling like they "belong to New Zealand." Another survey, of about 6,000, conducted by psychologist Marc Wilson of Victoria University of Wellington, found that Kiwi respondents with stronger identification to rugby reported being happier, more optimistic and having higher self-esteem. The beneficial effects of happiness on health are both obvious and well documented, and should not be underestimated. I wonder if the rugby in rugby culture could be replaced with a group activity with fewer downsides? Could a less dangerous and less rambunctious diversion replace rugby? Golf is popular here - so perhaps the All Greens might substitute. When it comes to group identity, however, such a change is much easier to talk about than to make. It's a bit like asking a Giants fan to take up an L.A. Dodger habit.
From your Kiwi Correspondent Part V
Here in New Zealand, I often reflect on October 2010. You may recall that month; the fall colors were black and orange and the season was flush with fearful beards and late-inning "torture." During those pennant-winning weeks, the cauldron of Giants baseball fever hovered between bubble and froth and our community had cohesion of purpose unlike I'd seen before.
So why is it that half-a-world away (where virtually no one knows the difference between a slider and a curveball) I'm consistently reminded of the 2010 World Champs? Well, it's because the fervour of fall '10 is replicated daily in New Zealand but for a much different sport: rugby.
New Zealand has been a rugby nation since shortly after its incorporation into the Crown territories in the early19th century. The British, you see, were intent on avoiding the opulent mentality that plagued prior empires, and so chose a formidable and stoic sport to promote throughout their colonies. I don't know how successful this tactic was elsewhere, but in New Zealand the game - and its paradigm - took root.. According to Dr. Robin McConnell, in his profile Inside the All Blacks, rugby "shapes New Zealand social history and everyday life." Case in point -- it's been five months since the New Zealand national team won the Rugby World Cup on home turf, yet the All Blacks remain ubiquitous. Flags, some homemade, fly from car antennas and balconies, babies don All Black onesies, and bottles of the nation's top selling beer (Steinlager) declare "All Blacks...25 Years of Unconditional Support." Looking for front-page news? Any snippet about a present or former All Blacks player will do. Did you know that the legendary Michael Jones is helping to bring a Carl's Jr. franchise to New Zealand?
The All Blacks are a national team and rugby a national sport in New Zealand - and we really have nothing comparable in the U.S., especially in terms of unity of loyalty. Given size and diversity differences between the two countries, this may not seem a fair comparison but it nonetheless raises the question of whether this shared passion for, and culture of, rugby pervades Kiwi life beyond the pitch? And in particular, does it help make Kiwis happier and healthier?
If you ask my wife, rugby is defined as a sport played by short men wearing too short shorts around gigantic thighs. But to others, it is defined by discipline, masculinity and stoicism. It is the type of sport in which a player (true story) might insist on playing most of a match with one testicle hanging torn from his scrotum. Stories like this are common and lead one to believe that the stoicism of Kiwis is unparalleled - an observation that finds some support in medical studies on pain tolerance. It could be that rugby plays a role in the Kiwi approach to death and dying [which is?]- one that, anecdotally at least, is more accepting than that of many other countries. Additionally, the national morale may be boosted by shared enthusiasm over rugby, which, in turn, can benefit the collective welfare. Indeed if you were to ask psychologist Jonathan Haidt, author of The Righteous Mind, Kiwi rugby culture might represent a classic case of sacredness of the group - "People who worship the same idol can trust one another, work as a team and prevail over less cohesive groups."
But some argue that any such benefits are greatly overwhelmed by rugby's culture of rowdiness, drunkenness and intolerance. In fact, just as there are Kiwis who live for rugby, there are those who detest it. One blogger, in a piece entitled "NZ Rugby Morally Bereft," writes that rugby "promotes machocism, alcoholism, violence, sexism and colonialism. Rugby has also created a crippling crisis in our health sector." There is certainly truth to the first statement - the only rugby match I've ever attended hosted a highly intoxicated crowd, and I won't even attempt to describe the experience of visiting a stadium urinal. But while injuries are common, I can't believe that they are a crippling crisis. Rugby may have a higher injury rate than many other sports, and concussions (especially under-reported concussions) are of particular concern, but the rates of devastating injuries such as spinal cord injury are actually not that high. A review of nationwide injury claims related to rugby from 1999-2007 reports an average of 743 a year, most of them limb and soft-tissue injuries, with a rather (given the nature of health expenses) modest yearly cost of $5.3 million.
One of the few academics that has closely studied and written about the cultural and societal effects of Kiwi rugby is Brendan Hokowhitu, an associate dean at University of Otago. He shares a rather bleak assessment of the health effects of the sport. "I wouldn't say there is anything historically at least positive about New Zealand rugby culture and health," he wrote. "Rugby was very much part of the establishment and was as such quite oppressive of women and alterity [cultural freedom] in general."
So the All Blacks culture does have a black side. But, to reiterate, the cohesiveness of the culture certainly has positive effects regarding national identity and group mentality. New Zealanders consistently score highly in international surveys of happiness and a nationwide social survey of 8,000 Kiwis found very high levels of people feeling like they "belong to New Zealand." Another survey, of about 6,000, conducted by psychologist Marc Wilson of Victoria University of Wellington, found that Kiwi respondents with stronger identification to rugby reported being happier, more optimistic and having higher self-esteem. The beneficial effects of happiness on health are both obvious and well documented, and should not be underestimated. I wonder if the rugby in rugby culture could be replaced with a group activity with fewer downsides? Could a less dangerous and less rambunctious diversion replace rugby? Golf is popular here - so perhaps the All Greens might substitute. When it comes to group identity, however, such a change is much easier to talk about than to make. It's a bit like asking a Giants fan to take up an L.A. Dodger habit.
From your Kiwi Correspondent Part V
Here in New Zealand, I often reflect on October 2010. You may recall that month; the fall colors were black and orange and the season was flush with fearful beards and late-inning "torture." During those pennant-winning weeks, the cauldron of Giants baseball fever hovered between bubble and froth and our community had cohesion of purpose unlike I'd seen before.
So why is it that half-a-world away (where virtually no one knows the difference between a slider and a curveball) I'm consistently reminded of the 2010 World Champs? Well, it's because the fervour of fall '10 is replicated daily in New Zealand but for a much different sport: rugby.
New Zealand has been a rugby nation since shortly after its incorporation into the Crown territories in the early19th century. The British, you see, were intent on avoiding the opulent mentality that plagued prior empires, and so chose a formidable and stoic sport to promote throughout their colonies. I don't know how successful this tactic was elsewhere, but in New Zealand the game - and its paradigm - took root.. According to Dr. Robin McConnell, in his profile Inside the All Blacks, rugby "shapes New Zealand social history and everyday life." Case in point -- it's been five months since the New Zealand national team won the Rugby World Cup on home turf, yet the All Blacks remain ubiquitous. Flags, some homemade, fly from car antennas and balconies, babies don All Black onesies, and bottles of the nation's top selling beer (Steinlager) declare "All Blacks...25 Years of Unconditional Support." Looking for front-page news? Any snippet about a present or former All Blacks player will do. Did you know that the legendary Michael Jones is helping to bring a Carl's Jr. franchise to New Zealand?
The All Blacks are a national team and rugby a national sport in New Zealand - and we really have nothing comparable in the U.S., especially in terms of unity of loyalty. Given size and diversity differences between the two countries, this may not seem a fair comparison but it nonetheless raises the question of whether this shared passion for, and culture of, rugby pervades Kiwi life beyond the pitch? And in particular, does it help make Kiwis happier and healthier?
If you ask my wife, rugby is defined as a sport played by short men wearing too short shorts around gigantic thighs. But to others, it is defined by discipline, masculinity and stoicism. It is the type of sport in which a player (true story) might insist on playing most of a match with one testicle hanging torn from his scrotum. Stories like this are common and lead one to believe that the stoicism of Kiwis is unparalleled - an observation that finds some support in medical studies on pain tolerance. It could be that rugby plays a role in the Kiwi approach to death and dying [which is?]- one that, anecdotally at least, is more accepting than that of many other countries. Additionally, the national morale may be boosted by shared enthusiasm over rugby, which, in turn, can benefit the collective welfare. Indeed if you were to ask psychologist Jonathan Haidt, author of The Righteous Mind, Kiwi rugby culture might represent a classic case of sacredness of the group - "People who worship the same idol can trust one another, work as a team and prevail over less cohesive groups."
But some argue that any such benefits are greatly overwhelmed by rugby's culture of rowdiness, drunkenness and intolerance. In fact, just as there are Kiwis who live for rugby, there are those who detest it. One blogger, in a piece entitled "NZ Rugby Morally Bereft," writes that rugby "promotes machocism, alcoholism, violence, sexism and colonialism. Rugby has also created a crippling crisis in our health sector." There is certainly truth to the first statement - the only rugby match I've ever attended hosted a highly intoxicated crowd, and I won't even attempt to describe the experience of visiting a stadium urinal. But while injuries are common, I can't believe that they are a crippling crisis. Rugby may have a higher injury rate than many other sports, and concussions (especially under-reported concussions) are of particular concern, but the rates of devastating injuries such as spinal cord injury are actually not that high. A review of nationwide injury claims related to rugby from 1999-2007 reports an average of 743 a year, most of them limb and soft-tissue injuries, with a rather (given the nature of health expenses) modest yearly cost of $5.3 million.
One of the few academics that has closely studied and written about the cultural and societal effects of Kiwi rugby is Brendan Hokowhitu, an associate dean at University of Otago. He shares a rather bleak assessment of the health effects of the sport. "I wouldn't say there is anything historically at least positive about New Zealand rugby culture and health," he wrote. "Rugby was very much part of the establishment and was as such quite oppressive of women and alterity [cultural freedom] in general."
So the All Blacks culture does have a black side. But, to reiterate, the cohesiveness of the culture certainly has positive effects regarding national identity and group mentality. New Zealanders consistently score highly in international surveys of happiness and a nationwide social survey of 8,000 Kiwis found very high levels of people feeling like they "belong to New Zealand." Another survey, of about 6,000, conducted by psychologist Marc Wilson of Victoria University of Wellington, found that Kiwi respondents with stronger identification to rugby reported being happier, more optimistic and having higher self-esteem. The beneficial effects of happiness on health are both obvious and well documented, and should not be underestimated. I wonder if the rugby in rugby culture could be replaced with a group activity with fewer downsides? Could a less dangerous and less rambunctious diversion replace rugby? Golf is popular here - so perhaps the All Greens might substitute. When it comes to group identity, however, such a change is much easier to talk about than to make. It's a bit like asking a Giants fan to take up an L.A. Dodger habit.
laughingsquid: Wound Specific I’d say people with the…
I'd say people with the afore-mentioned weapon injuries typically don't do well with just a bandaid.
Lessons From One Hot Joint
One thing I love about Emergency Medicine is that no two cases of the same disease are ever exactly alike. Yes this can be anxiety provoking, but I prefer to think of it as akin to great jazz tunes – it nostalgically reminds you of other versions of a song you’ve heard before, but the players and the riffs are distinctly unique.
A case in point, the hot joint has presented some interesting challenges to me on a number of cases. Most recently, a thirty something intravenous drug user with several days of increasing pain, redness, swelling of her left shoulder appeared for all the world to be a septic joint. She had a great history, classic presentation, and initial labs showed and white count, ESR, and CRP through the roof. Now I love doing taps, but in our ED we involve orthopedics for many of them, particularly the shoulders. The talented orthopedic resident to my surprise was not interested in tapping it.
My initial response to him was that no matter what you tell me the pretest probability that this IV drug user has a septic joint is so high, no test other than an arthrocentesis is going to satisfy me. But the orthopedic resident had some interesting and valid concerns, and the more I thought about it the more I recognized that there were some interesting clues along the way that led away from a septic joint:
1. The pain began after direct inoculation with a needle into the shoulder (rather than by hematogenous spread of bacteria to the joint from an intravenous needle) so it seemed unlikely to me that the patient had jammed a needle all the way into her glenohumeral joint.
2. The patient really didn’t want to move the shoulder at all, and was guarding it gingerly, but in fact with gentle passive range of motion there was a few degrees of flexion and extension, in contrast the patient did not want to abduct at all, offering the possibility of an infected subacromial bursitis
The orthopedic resident was concerned that putting a needle into the joint through an infected abscess or bursitis would potentially seed a sterile joint with bacteria and make things worse, so we agreed on a quick initial ultrasound. This was read by radiology as a septic joint, with increased joint space fluid and surrounding reactive hyper-vascularity.
At this point we tapped the joint. Our posterior approach was a dry tap. Frustrating as this was, it was clear we were in the joint space, but there was nothing.
So what now. If this was a deltoid abscess, having orthopedics open up the joint would be a mistake. An MRI would have been nice but she actually had an old needles embedded in her shoulder from prior injections so that made radiology put their foot down on that one…
So a CT of the shoulder was done which again was read as a septic joint with fluid around the joint space. Remarkably the joint space itself was well-preserved on my read of the CT, which seemed odd to me. My only thought at the time was that the direct inoculation of the joint had made a tract anteriorly through which the pus was draining and surrounding the joint capsule externally.
Ultimately orthopedics took her to the OR. There they found a septic bursitis that had ruptured anteriorly and surrounded the joint capsule with pus and fluid. The integrity of the joint itself was well maintained. Ultimately, the patient did very well and went home several days after admission on antibiotics.
The take home points for me.
- Think about abscess or infected bursitis before sticking a needle into a joint. You could make things worse if you plunge a needle through infected tissue into a sterile joint space.
- Any inflammatory markers in this situation are utterly useless.
- Imaging can be falsely positive and may again lead to attempted arthrocentesis.
- Complex infections around a joint are still best served on orthopedics. There was some discussion about general surgery involvement for abscess drainage, but given the high likelihood of joint involvement in an equivocal case like this orthopedics is better equipped to debride and wash out around joint structures.
Until recently most of my thinking about red-hot and swollen joints are “what fun I get to tap it” and second I think, “when do I get to tap it”. This general teaching holds true for most cases, but I have recently been humbled by missed taps, indeterminate taps which turn out to be infectious not inflammatory, and the reverse, cases that got unnecessary wash-outs. So my belief that the hot joint is the last bastion of simple diagnostic procedures in the ED has been finally crushed. There you are, you either love jazz or you don’t…
Filed under: Uncategorized
Permission to Take Blood
A sprightly 72 year old came into the office for a prescription refill and blood pressure check. His tie was tightly knotted, thick hair combed into place, and shoes well polished.
We asked him once more if we could take blood to screen him for the routine things; high cholesterol, diabetes, prostate antigen. Once more he said, no doctor, I don't want to know if something is a brewin'. Not interested.
Joe pressed him a little, sure come on now, are you sure you wont let us?
To which his eyes shone a little brighter and he answered, listen Joe...if I walk out into the street and collapse in front of the surgery, tell ya what, I give you permission to take as much blood as you want.
Fair enough!
We asked him once more if we could take blood to screen him for the routine things; high cholesterol, diabetes, prostate antigen. Once more he said, no doctor, I don't want to know if something is a brewin'. Not interested.
Joe pressed him a little, sure come on now, are you sure you wont let us?
To which his eyes shone a little brighter and he answered, listen Joe...if I walk out into the street and collapse in front of the surgery, tell ya what, I give you permission to take as much blood as you want.
Fair enough!
Permission to Take Blood
A sprightly 72 year old came into the office for a prescription refill and blood pressure check. His tie was tightly knotted, thick hair combed into place, and shoes well polished.
We asked him once more if we could take blood to screen him for the routine things; high cholesterol, diabetes, prostate antigen. Once more he said, no doctor, I don't want to know if something is a brewin'. Not interested.
Joe pressed him a little, sure come on now, are you sure you wont let us?
To which his eyes shone a little brighter and he answered, listen Joe...if I walk out into the street and collapse in front of the surgery, tell ya what, I give you permission to take as much blood as you want.
Fair enough!
We asked him once more if we could take blood to screen him for the routine things; high cholesterol, diabetes, prostate antigen. Once more he said, no doctor, I don't want to know if something is a brewin'. Not interested.
Joe pressed him a little, sure come on now, are you sure you wont let us?
To which his eyes shone a little brighter and he answered, listen Joe...if I walk out into the street and collapse in front of the surgery, tell ya what, I give you permission to take as much blood as you want.
Fair enough!
EDExam Podcast – Episode 2 – Luigi Marino (Part 1)
Here's the 2nd epsiode of the EDExam Podcast. I was lucky enough to have a fantastic study partner when I went through the Fellowship Exam, in the form of Dr Luigi Marino. Luigi is a FACEM from Melbourne, and in this, the first of a multi-part interview he dishes out a whole heap of pearls about preparing for the exam, from dealing with feelings of animosity toward the exam process, to being strategic about where you're working when you sit the exam, through to some specifics about study technique. He was so generous with his time that I had to keep picking his brains, so I've split the interview into a few parts. Watch out for part 2, coming soon!
Enjoy.
(Click on the play button to stream it, or hit Download to save it) {audio}Episode_2_Luigi_Marino_Part_1.mp3{/audio}
You can also subscribe in iTunes, and if you like it be sure to give it a 5-star rating, thanks!
SMART Testing: Back to basics
In medicine we love us a good diagnostic test; we're always looking for the next one. It is strange, then, that we should be so aloof to the basics of diagnostic testing. This month's audio is a primer on testing—and it changes everything. We're going back to basics: if you learn the four axioms of diagnostic testing you'll know more about how to choose and how to interpret diagnostic tests than just about everyone. Weird thing is that it turns out you knew it all already... you just needed a reminder.
How to Post a Case or Question to EMCrit Google Plus
I get a ton of clinical cases and questions by email or the contact form on the blog. I love this–it exposes me to some great cases I would never hear about otherwise. Problem is, up until this point, it has been a 1 on 1 conversation. This is sort of a waste because nobody else benefits except you and me. So in the future, when you have a case or question like this, I would love it if you posted to the Google Plus EMCrit page. This allows a few things:
- it allows my answer to be seen by a much larger group of people
- it allows folks smarter than me to chime in as well
- it keeps a record of these case interactions so I can refer people to them in the future
So how do you do it? Easiest way to learn is to watch this video:
Click here to view the embedded video.
Here are the Steps Outlined
1. Go to the Google Plus EMCrit page
2. Click on the follow link
3. You may be asked to log-in or create a google account
4. Go to the share button in the upper right of the screen
5. Type “+emcrit” and choose the emcrit logo that appears
6. Type in your case
7. Make sure to leave the public sharing alone
8. Click Share
9. Check back on the EMCrit Google Plus Page to see the responses
You just read the post: How to Post a Case or Question to EMCrit Google Plus from EMCrit Blog - Emergency Department Critical Care.
How LR works. Why any test is unnecessary for a patient with very low-risk chest pain ?
A 40 yo truck driver, presented in ED with substernal chest pain. He is healthy, no family history of CAD. Held for observation, serial ECG have not modified, not elevated troponin.
The pretest probability of CAD in this setting is less than 2%.
Conclusion
This is a classic example of how LR works. A very low pretest makes unnecessary further testing to confirm that. If negative or positive the post test probability changes a low. A positive test may lead the patient to undergo an invasive, dangerous and unnecessary test like coronary angiography. Patients with a very low pretest probability of CAD do not require further testing.
It is very surprising how low is LR of ETT ....this should be a material for next discussion.
Bibliography
EA Amsterdam et al
Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain.
Circulation 2010, 122:1756-1776
LK Hermann et al
The limited utility of routine cardiac stress testing in Emergency Department chest pain patients younger than 40 years.
Ann Emerg Med vol 54 n1 2009
JM Kosowsky
Approach to the ED patient with low risk chest pain.
Emerg Med Clin N Am 29 2011 721-727
Ciro Paolillo
How LR works. Why any test is unnecessary for a patient with very low-risk chest pain ?
A 40 yo truck driver, presented in ED with substernal chest pain. He is healthy, no family history of CAD. Held for observation, serial ECG have not modified, not elevated troponin.The pretest probability of CAD in this setting is less than 2%.
Conclusion
This is a classic example of how LR works. A very low pretest makes unnecessary further testing to confirm that. If negative or positive the post test probability changes a low. A positive test may lead the patient to undergo an invasive, dangerous and unnecessary test like coronary angiography. Patients with a very low pretest probability of CAD do not require further testing.
It is very surprising how low is LR of ETT ....this should be a material for next discussion.
Bibliography
EA Amsterdam et al
Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain.
Circulation 2010, 122:1756-1776
LK Hermann et al
The limited utility of routine cardiac stress testing in Emergency Department chest pain patients younger than 40 years.
Ann Emerg Med vol 54 n1 2009
JM Kosowsky
Approach to the ED patient with low risk chest pain.
Emerg Med Clin N Am 29 2011 721-727
Ciro Paolillo
How LR works. Why any test is unnecessary for a patient with very low-risk chest pain ?
A 40 yo truck driver, presented in ED with substernal chest pain. He is healthy, no family history of CAD. Held for observation, serial ECG have not modified, not elevated troponin.The pretest probability of CAD in this setting is less than 2%.
Conclusion
This is a classic example of how LR works. A very low pretest makes unnecessary further testing to confirm that. If negative or positive the post test probability changes a low. A positive test may lead the patient to undergo an invasive, dangerous and unnecessary test like coronary angiography. Patients with a very low pretest probability of CAD do not require further testing.
It is very surprising how low is LR of ETT ....this should be a material for next discussion.
Bibliography
EA Amsterdam et al
Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain.
Circulation 2010, 122:1756-1776
LK Hermann et al
The limited utility of routine cardiac stress testing in Emergency Department chest pain patients younger than 40 years.
Ann Emerg Med vol 54 n1 2009
JM Kosowsky
Approach to the ED patient with low risk chest pain.
Emerg Med Clin N Am 29 2011 721-727
Ciro Paolillo
The Interview
A few years back, my wife and I were sitting on our living room couch watching the local evening news when a segment ran regarding a patient's option, often neglected, to interview a physician prior to agreeing to receive care from that particular caretaker. The interview, the segment continued, could involve questions ranging from professional training to personal attitudes and outlooks on life. Not a bad idea, I reasoned, if the required care was non-emergent. A physician sharing a similar perspective of his patient's well-being could only be beneficial, right? But in an emergency room setting, wouldn't this type of interview only delay necessary treatment? I couldn't imagine a patient with crushing chest pain taking the time to ask me of my residency training (Upstate NY) or how I felt about fitness training (all for it).
Of course, I was wrong. My following shift, I encountered an older, scholarly-looking gentleman who had presented to our department with complaints of acute abdominal pain. After introducing myself to both himself and his wife, I began to ask the patient important history questions when he suddenly interrupted me.
"Doctor," he asked, "before I agree to let you treat me, can you tell me where you went to medical school?" Although surprised, after watching the news segment just two days earlier, I anticipated that an encounter like this would eventually happen. "In Philadelphia," I answered. "And where in your class did you graduate?" "In the top ten percent," I replied. His questions kept coming. "And where did you complete your residency?" "Did you serve as chief resident your final year?" "How long have you been working in this emergency room?" As I patiently answered his questions, I began to wonder if the word "acute" was the right word to describe his abdominal pain.
Finally, though, he appeared satisfied with his interview. "Okay," he said, "I give you permission to treat me."
"Well, sir," I said, deciding to turn the tables on him, "I am not sure I want to treat you." I caught him off-guard. He looked inquisitively at me as I paused for good effect before continuing. "I have one question I want to ask you before I agree to treat you."
"Okay, Doctor," he said, "what is it?"
I took a deep breath and smiled as I spoke. "How will you be paying me for your visit today?" We both laughed. Regardless of his answer, he knew I would be his treating physician.
I hadn't thought about this encounter until just recently, after I had walked into Room 17 to introduce myself and examine a patient my resident was currently treating.
In the dimly-lit room, I found Bertha, alone without company, lying in a cot with hospital blankets pulled up to her chin. She was a 93 year-old woman sent to us from a local rehabilitation unit with complaints of chest pain. She had been placed there recently to recover from a bout of pneumonia. Bertha looked her age, appearing frail in size, her tiny body barely poking it's physicality into her covering sheets. Her face was graced with creviced wrinkles and framed with an unkempt gray bob. Her hazel eyes, however, belied her years. They were fierce and focused, guarded even, glistening with anticipation as I approached to introduce myself.
"Hello, ma'am," I said, reaching for her hand under her covers, "my name is Dr. Jim and I will be following your treatment today with Dr. Brad, one of our resident physicians who I am supervising."
She looked me carefully up and down as I continued. "Is your chest pain gone?" She nodded yes to my question. "Do you need anything right now?" She nodded no. "Is it okay, ma'am, if I listen to your heart and lungs?" She nodded yes.
I pulled my stethoscope from around my neck, placing it's diaphragm on her chest wall while inserting the listening buds into my ears. While bent over her and listening, I watched her face closely, appreciating her unique eyes. Suddenly, though, her lips moved. Unable to hear her, I stood up while removing the ear buds. "What is that, ma'am?" I asked.
With a soft, quiet voice, she asked me "Where did you go to medical school?" I told her. "And where did you do residency?" I answered her again. "Do you enjoy being a doctor?" I told her yes, very much so. I wasn't sure if another interview was in my future, so I flipped the coin on her.
"Why do you ask, ma'am?" I questioned her. "Did you once work in the medical field?"
She shook her head. "No, I didn't. But my daughter was going to be a nurse." I waited for her to continue but she seemed absorbed in her memory. "What happened?" I finally asked, my curiosity peaked. "Unfortunately," Bertha answered, sadness sweeping across her face, "she wrecked her car late one night while driving home from a training shift and died. She was nineteen."
I grabbed Bertha's hand again and held it, humbly reminded that every face I encounter holds a story. And quite honestly, I could not even begin to imagine the pain that would come with losing a child. "I'm so sorry," I said, stroking the back of her hand.
"Don't be," she said, "I still had a wonderful life." She went on to explain that she had six children total, four of which were still alive but unfortunately not nearby geographically. This explained why she had been placed into a rehab unit from her assisted-living arrangement while recovering from pneumonia. "They are here, though," she said, lightly tapping her heart with her free hand.
After another pause, I had to ask my next question. "What happened to your other child?" "Oh," she answered thoughtfully, "we had a retarded son that died in adulthood. My husband and I managed to care for him at home until he passed." She went on to proudly explain that it was no small feat to raise a mentally-challenged child in earlier days--that most were institutionalized. "And your husband?" I asked. "Well, he and I were married for 53 years before he passed away. That was quite a few years ago. But, we managed to stay together and keep our love the whole time." We talked a few more minutes, her insightful words leaving a significant imprint upon me.
Finally, I finished my exam. Before leaving her, I thanked Bertha for her time and for sharing her life story with me. Happily, she did very well for us in the ER and was admitted to observation.
Just returning from my recent unplanned medical leave, I felt Bertha's story grab my shoulders and shake me. Not just shake me, but rattle my soul. My encounter with her was a well-timed reminder of just how privileged I was to be an emergency physician.
And suddenly, it dawned on me. I was the one who benefited most from the interview process with a patient. Sure, there is history-taking involved with my job, to find out the specifics of an illness that might help me provide the most focused and complete care to a patient. But this other "stuff," this personal information that a patient shares with me, isn't this more like an interview? I don't necessarily need to know everything a patient shares, but doesn't it all provide a much more complete picture of the person I am trying to help? And, besides, can't some of my patients' shared life experiences help me along my own life's journey?
A resounding yes and yes, if you ask me. I think I'm going to call the local news station and thank them for their meaningful segment...
As always, big thanks for reading. Also, a HUGE thank you to all the personal emails and posted comments from my last posting. Your warm welcomes and kind words are greatly appreciated. I have some of the coolest readers ever...
Of course, I was wrong. My following shift, I encountered an older, scholarly-looking gentleman who had presented to our department with complaints of acute abdominal pain. After introducing myself to both himself and his wife, I began to ask the patient important history questions when he suddenly interrupted me.
"Doctor," he asked, "before I agree to let you treat me, can you tell me where you went to medical school?" Although surprised, after watching the news segment just two days earlier, I anticipated that an encounter like this would eventually happen. "In Philadelphia," I answered. "And where in your class did you graduate?" "In the top ten percent," I replied. His questions kept coming. "And where did you complete your residency?" "Did you serve as chief resident your final year?" "How long have you been working in this emergency room?" As I patiently answered his questions, I began to wonder if the word "acute" was the right word to describe his abdominal pain.
Finally, though, he appeared satisfied with his interview. "Okay," he said, "I give you permission to treat me."
"Well, sir," I said, deciding to turn the tables on him, "I am not sure I want to treat you." I caught him off-guard. He looked inquisitively at me as I paused for good effect before continuing. "I have one question I want to ask you before I agree to treat you."
"Okay, Doctor," he said, "what is it?"
I took a deep breath and smiled as I spoke. "How will you be paying me for your visit today?" We both laughed. Regardless of his answer, he knew I would be his treating physician.
I hadn't thought about this encounter until just recently, after I had walked into Room 17 to introduce myself and examine a patient my resident was currently treating.
In the dimly-lit room, I found Bertha, alone without company, lying in a cot with hospital blankets pulled up to her chin. She was a 93 year-old woman sent to us from a local rehabilitation unit with complaints of chest pain. She had been placed there recently to recover from a bout of pneumonia. Bertha looked her age, appearing frail in size, her tiny body barely poking it's physicality into her covering sheets. Her face was graced with creviced wrinkles and framed with an unkempt gray bob. Her hazel eyes, however, belied her years. They were fierce and focused, guarded even, glistening with anticipation as I approached to introduce myself.
"Hello, ma'am," I said, reaching for her hand under her covers, "my name is Dr. Jim and I will be following your treatment today with Dr. Brad, one of our resident physicians who I am supervising."
She looked me carefully up and down as I continued. "Is your chest pain gone?" She nodded yes to my question. "Do you need anything right now?" She nodded no. "Is it okay, ma'am, if I listen to your heart and lungs?" She nodded yes.
I pulled my stethoscope from around my neck, placing it's diaphragm on her chest wall while inserting the listening buds into my ears. While bent over her and listening, I watched her face closely, appreciating her unique eyes. Suddenly, though, her lips moved. Unable to hear her, I stood up while removing the ear buds. "What is that, ma'am?" I asked.
With a soft, quiet voice, she asked me "Where did you go to medical school?" I told her. "And where did you do residency?" I answered her again. "Do you enjoy being a doctor?" I told her yes, very much so. I wasn't sure if another interview was in my future, so I flipped the coin on her.
"Why do you ask, ma'am?" I questioned her. "Did you once work in the medical field?"
She shook her head. "No, I didn't. But my daughter was going to be a nurse." I waited for her to continue but she seemed absorbed in her memory. "What happened?" I finally asked, my curiosity peaked. "Unfortunately," Bertha answered, sadness sweeping across her face, "she wrecked her car late one night while driving home from a training shift and died. She was nineteen."
I grabbed Bertha's hand again and held it, humbly reminded that every face I encounter holds a story. And quite honestly, I could not even begin to imagine the pain that would come with losing a child. "I'm so sorry," I said, stroking the back of her hand.
"Don't be," she said, "I still had a wonderful life." She went on to explain that she had six children total, four of which were still alive but unfortunately not nearby geographically. This explained why she had been placed into a rehab unit from her assisted-living arrangement while recovering from pneumonia. "They are here, though," she said, lightly tapping her heart with her free hand.
After another pause, I had to ask my next question. "What happened to your other child?" "Oh," she answered thoughtfully, "we had a retarded son that died in adulthood. My husband and I managed to care for him at home until he passed." She went on to proudly explain that it was no small feat to raise a mentally-challenged child in earlier days--that most were institutionalized. "And your husband?" I asked. "Well, he and I were married for 53 years before he passed away. That was quite a few years ago. But, we managed to stay together and keep our love the whole time." We talked a few more minutes, her insightful words leaving a significant imprint upon me.
Finally, I finished my exam. Before leaving her, I thanked Bertha for her time and for sharing her life story with me. Happily, she did very well for us in the ER and was admitted to observation.
Just returning from my recent unplanned medical leave, I felt Bertha's story grab my shoulders and shake me. Not just shake me, but rattle my soul. My encounter with her was a well-timed reminder of just how privileged I was to be an emergency physician.
And suddenly, it dawned on me. I was the one who benefited most from the interview process with a patient. Sure, there is history-taking involved with my job, to find out the specifics of an illness that might help me provide the most focused and complete care to a patient. But this other "stuff," this personal information that a patient shares with me, isn't this more like an interview? I don't necessarily need to know everything a patient shares, but doesn't it all provide a much more complete picture of the person I am trying to help? And, besides, can't some of my patients' shared life experiences help me along my own life's journey?
A resounding yes and yes, if you ask me. I think I'm going to call the local news station and thank them for their meaningful segment...
As always, big thanks for reading. Also, a HUGE thank you to all the personal emails and posted comments from my last posting. Your warm welcomes and kind words are greatly appreciated. I have some of the coolest readers ever...
The Interview
A few years back, my wife and I were sitting on our living room couch watching the local evening news when a segment ran regarding a patient's option, often neglected, to interview a physician prior to agreeing to receive care from that particular caretaker. The interview, the segment continued, could involve questions ranging from professional training to personal attitudes and outlooks on life. Not a bad idea, I reasoned, if the required care was non-emergent. A physician sharing a similar perspective of his patient's well-being could only be beneficial, right? But in an emergency room setting, wouldn't this type of interview only delay necessary treatment? I couldn't imagine a patient with crushing chest pain taking the time to ask me of my residency training (Upstate NY) or how I felt about fitness training (all for it).
Of course, I was wrong. My following shift, I encountered an older, scholarly-looking gentleman who had presented to our department with complaints of acute abdominal pain. After introducing myself to both himself and his wife, I began to ask the patient important history questions when he suddenly interrupted me.
"Doctor," he asked, "before I agree to let you treat me, can you tell me where you went to medical school?" Although surprised, after watching the news segment just two days earlier, I anticipated that an encounter like this would eventually happen. "In Philadelphia," I answered. "And where in your class did you graduate?" "In the top ten percent," I replied. His questions kept coming. "And where did you complete your residency?" "Did you serve as chief resident your final year?" "How long have you been working in this emergency room?" As I patiently answered his questions, I began to wonder if the word "acute" was the right word to describe his abdominal pain.
Finally, though, he appeared satisfied with his interview. "Okay," he said, "I give you permission to treat me."
"Well, sir," I said, deciding to turn the tables on him, "I am not sure I want to treat you." I caught him off-guard. He looked inquisitively at me as I paused for good effect before continuing. "I have one question I want to ask you before I agree to treat you."
"Okay, Doctor," he said, "what is it?"
I took a deep breath and smiled as I spoke. "How will you be paying me for your visit today?" We both laughed. Regardless of his answer, he knew I would be his treating physician.
I hadn't thought about this encounter until just recently, after I had walked into Room 17 to introduce myself and examine a patient my resident was currently treating.
In the dimly-lit room, I found Bertha, alone without company, lying in a cot with hospital blankets pulled up to her chin. She was a 93 year-old woman sent to us from a local rehabilitation unit with complaints of chest pain. She had been placed there recently to recover from a bout of pneumonia. Bertha looked her age, appearing frail in size, her tiny body barely poking it's physicality into her covering sheets. Her face was graced with creviced wrinkles and framed with an unkempt gray bob. Her hazel eyes, however, belied her years. They were fierce and focused, guarded even, glistening with anticipation as I approached to introduce myself.
"Hello, ma'am," I said, reaching for her hand under her covers, "my name is Dr. Jim and I will be following your treatment today with Dr. Brad, one of our resident physicians who I am supervising."
She looked me carefully up and down as I continued. "Is your chest pain gone?" She nodded yes to my question. "Do you need anything right now?" She nodded no. "Is it okay, ma'am, if I listen to your heart and lungs?" She nodded yes.
I pulled my stethoscope from around my neck, placing it's diaphragm on her chest wall while inserting the listening buds into my ears. While bent over her and listening, I watched her face closely, appreciating her unique eyes. Suddenly, though, her lips moved. Unable to hear her, I stood up while removing the ear buds. "What is that, ma'am?" I asked.
With a soft, quiet voice, she asked me "Where did you go to medical school?" I told her. "And where did you do residency?" I answered her again. "Do you enjoy being a doctor?" I told her yes, very much so. I wasn't sure if another interview was in my future, so I flipped the coin on her.
"Why do you ask, ma'am?" I questioned her. "Did you once work in the medical field?"
She shook her head. "No, I didn't. But my daughter was going to be a nurse." I waited for her to continue but she seemed absorbed in her memory. "What happened?" I finally asked, my curiosity peaked. "Unfortunately," Bertha answered, sadness sweeping across her face, "she wrecked her car late one night while driving home from a training shift and died. She was nineteen."
I grabbed Bertha's hand again and held it, humbly reminded that every face I encounter holds a story. And quite honestly, I could not even begin to imagine the pain that would come with losing a child. "I'm so sorry," I said, stroking the back of her hand.
"Don't be," she said, "I still had a wonderful life." She went on to explain that she had six children total, four of which were still alive but unfortunately not nearby geographically. This explained why she had been placed into a rehab unit from her assisted-living arrangement while recovering from pneumonia. "They are here, though," she said, lightly tapping her heart with her free hand.
After another pause, I had to ask my next question. "What happened to your other child?" "Oh," she answered thoughtfully, "we had a retarded son that died in adulthood. My husband and I managed to care for him at home until he passed." She went on to proudly explain that it was no small feat to raise a mentally-challenged child in earlier days--that most were institutionalized. "And your husband?" I asked. "Well, he and I were married for 53 years before he passed away. That was quite a few years ago. But, we managed to stay together and keep our love the whole time." We talked a few more minutes, her insightful words leaving a significant imprint upon me.
Finally, I finished my exam. Before leaving her, I thanked Bertha for her time and for sharing her life story with me. Happily, she did very well for us in the ER and was admitted to observation.
Just returning from my recent unplanned medical leave, I felt Bertha's story grab my shoulders and shake me. Not just shake me, but rattle my soul. My encounter with her was a well-timed reminder of just how privileged I was to be an emergency physician.
And suddenly, it dawned on me. I was the one who benefited most from the interview process with a patient. Sure, there is history-taking involved with my job, to find out the specifics of an illness that might help me provide the most focused and complete care to a patient. But this other "stuff," this personal information that a patient shares with me, isn't this more like an interview? I don't necessarily need to know everything a patient shares, but doesn't it all provide a much more complete picture of the person I am trying to help? And, besides, can't some of my patients' shared life experiences help me along my own life's journey?
A resounding yes and yes, if you ask me. I think I'm going to call the local news station and thank them for their meaningful segment...
As always, big thanks for reading. Also, a HUGE thank you to all the personal emails and posted comments from my last posting. Your warm welcomes and kind words are greatly appreciated. I have some of the coolest readers ever...
Of course, I was wrong. My following shift, I encountered an older, scholarly-looking gentleman who had presented to our department with complaints of acute abdominal pain. After introducing myself to both himself and his wife, I began to ask the patient important history questions when he suddenly interrupted me.
"Doctor," he asked, "before I agree to let you treat me, can you tell me where you went to medical school?" Although surprised, after watching the news segment just two days earlier, I anticipated that an encounter like this would eventually happen. "In Philadelphia," I answered. "And where in your class did you graduate?" "In the top ten percent," I replied. His questions kept coming. "And where did you complete your residency?" "Did you serve as chief resident your final year?" "How long have you been working in this emergency room?" As I patiently answered his questions, I began to wonder if the word "acute" was the right word to describe his abdominal pain.
Finally, though, he appeared satisfied with his interview. "Okay," he said, "I give you permission to treat me."
"Well, sir," I said, deciding to turn the tables on him, "I am not sure I want to treat you." I caught him off-guard. He looked inquisitively at me as I paused for good effect before continuing. "I have one question I want to ask you before I agree to treat you."
"Okay, Doctor," he said, "what is it?"
I took a deep breath and smiled as I spoke. "How will you be paying me for your visit today?" We both laughed. Regardless of his answer, he knew I would be his treating physician.
I hadn't thought about this encounter until just recently, after I had walked into Room 17 to introduce myself and examine a patient my resident was currently treating.
In the dimly-lit room, I found Bertha, alone without company, lying in a cot with hospital blankets pulled up to her chin. She was a 93 year-old woman sent to us from a local rehabilitation unit with complaints of chest pain. She had been placed there recently to recover from a bout of pneumonia. Bertha looked her age, appearing frail in size, her tiny body barely poking it's physicality into her covering sheets. Her face was graced with creviced wrinkles and framed with an unkempt gray bob. Her hazel eyes, however, belied her years. They were fierce and focused, guarded even, glistening with anticipation as I approached to introduce myself.
"Hello, ma'am," I said, reaching for her hand under her covers, "my name is Dr. Jim and I will be following your treatment today with Dr. Brad, one of our resident physicians who I am supervising."
She looked me carefully up and down as I continued. "Is your chest pain gone?" She nodded yes to my question. "Do you need anything right now?" She nodded no. "Is it okay, ma'am, if I listen to your heart and lungs?" She nodded yes.
I pulled my stethoscope from around my neck, placing it's diaphragm on her chest wall while inserting the listening buds into my ears. While bent over her and listening, I watched her face closely, appreciating her unique eyes. Suddenly, though, her lips moved. Unable to hear her, I stood up while removing the ear buds. "What is that, ma'am?" I asked.
With a soft, quiet voice, she asked me "Where did you go to medical school?" I told her. "And where did you do residency?" I answered her again. "Do you enjoy being a doctor?" I told her yes, very much so. I wasn't sure if another interview was in my future, so I flipped the coin on her.
"Why do you ask, ma'am?" I questioned her. "Did you once work in the medical field?"
She shook her head. "No, I didn't. But my daughter was going to be a nurse." I waited for her to continue but she seemed absorbed in her memory. "What happened?" I finally asked, my curiosity peaked. "Unfortunately," Bertha answered, sadness sweeping across her face, "she wrecked her car late one night while driving home from a training shift and died. She was nineteen."
I grabbed Bertha's hand again and held it, humbly reminded that every face I encounter holds a story. And quite honestly, I could not even begin to imagine the pain that would come with losing a child. "I'm so sorry," I said, stroking the back of her hand.
"Don't be," she said, "I still had a wonderful life." She went on to explain that she had six children total, four of which were still alive but unfortunately not nearby geographically. This explained why she had been placed into a rehab unit from her assisted-living arrangement while recovering from pneumonia. "They are here, though," she said, lightly tapping her heart with her free hand.
After another pause, I had to ask my next question. "What happened to your other child?" "Oh," she answered thoughtfully, "we had a retarded son that died in adulthood. My husband and I managed to care for him at home until he passed." She went on to proudly explain that it was no small feat to raise a mentally-challenged child in earlier days--that most were institutionalized. "And your husband?" I asked. "Well, he and I were married for 53 years before he passed away. That was quite a few years ago. But, we managed to stay together and keep our love the whole time." We talked a few more minutes, her insightful words leaving a significant imprint upon me.
Finally, I finished my exam. Before leaving her, I thanked Bertha for her time and for sharing her life story with me. Happily, she did very well for us in the ER and was admitted to observation.
Just returning from my recent unplanned medical leave, I felt Bertha's story grab my shoulders and shake me. Not just shake me, but rattle my soul. My encounter with her was a well-timed reminder of just how privileged I was to be an emergency physician.
And suddenly, it dawned on me. I was the one who benefited most from the interview process with a patient. Sure, there is history-taking involved with my job, to find out the specifics of an illness that might help me provide the most focused and complete care to a patient. But this other "stuff," this personal information that a patient shares with me, isn't this more like an interview? I don't necessarily need to know everything a patient shares, but doesn't it all provide a much more complete picture of the person I am trying to help? And, besides, can't some of my patients' shared life experiences help me along my own life's journey?
A resounding yes and yes, if you ask me. I think I'm going to call the local news station and thank them for their meaningful segment...
As always, big thanks for reading. Also, a HUGE thank you to all the personal emails and posted comments from my last posting. Your warm welcomes and kind words are greatly appreciated. I have some of the coolest readers ever...
The Interview
A few years back, my wife and I were sitting on our living room couch watching the local evening news when a segment ran regarding a patient's option, often neglected, to interview a physician prior to agreeing to receive care from that particular caretaker. The interview, the segment continued, could involve questions ranging from professional training to personal attitudes and outlooks on life. Not a bad idea, I reasoned, if the required care was non-emergent. A physician sharing a similar perspective of his patient's well-being could only be beneficial, right? But in an emergency room setting, wouldn't this type of interview only delay necessary treatment? I couldn't imagine a patient with crushing chest pain taking the time to ask me of my residency training (Upstate NY) or how I felt about fitness training (all for it).
Of course, I was wrong. My following shift, I encountered an older, scholarly-looking gentleman who had presented to our department with complaints of acute abdominal pain. After introducing myself to both himself and his wife, I began to ask the patient important history questions when he suddenly interrupted me.
"Doctor," he asked, "before I agree to let you treat me, can you tell me where you went to medical school?" Although surprised, after watching the news segment just two days earlier, I anticipated that an encounter like this would eventually happen. "In Philadelphia," I answered. "And where in your class did you graduate?" "In the top ten percent," I replied. His questions kept coming. "And where did you complete your residency?" "Did you serve as chief resident your final year?" "How long have you been working in this emergency room?" As I patiently answered his questions, I began to wonder if the word "acute" was the right word to describe his abdominal pain.
Finally, though, he appeared satisfied with his interview. "Okay," he said, "I give you permission to treat me."
"Well, sir," I said, deciding to turn the tables on him, "I am not sure I want to treat you." I caught him off-guard. He looked inquisitively at me as I paused for good effect before continuing. "I have one question I want to ask you before I agree to treat you."
"Okay, Doctor," he said, "what is it?"
I took a deep breath and smiled as I spoke. "How will you be paying me for your visit today?" We both laughed. Regardless of his answer, he knew I would be his treating physician.
I hadn't thought about this encounter until just recently, after I had walked into Room 17 to introduce myself and examine a patient my resident was currently treating.
In the dimly-lit room, I found Bertha, alone without company, lying in a cot with hospital blankets pulled up to her chin. She was a 93 year-old woman sent to us from a local rehabilitation unit with complaints of chest pain. She had been placed there recently to recover from a bout of pneumonia. Bertha looked her age, appearing frail in size, her tiny body barely poking it's physicality into her covering sheets. Her face was graced with creviced wrinkles and framed with an unkempt gray bob. Her hazel eyes, however, belied her years. They were fierce and focused, guarded even, glistening with anticipation as I approached to introduce myself.
"Hello, ma'am," I said, reaching for her hand under her covers, "my name is Dr. Jim and I will be following your treatment today with Dr. Brad, one of our resident physicians who I am supervising."
She looked me carefully up and down as I continued. "Is your chest pain gone?" She nodded yes to my question. "Do you need anything right now?" She nodded no. "Is it okay, ma'am, if I listen to your heart and lungs?" She nodded yes.
I pulled my stethoscope from around my neck, placing it's diaphragm on her chest wall while inserting the listening buds into my ears. While bent over her and listening, I watched her face closely, appreciating her unique eyes. Suddenly, though, her lips moved. Unable to hear her, I stood up while removing the ear buds. "What is that, ma'am?" I asked.
With a soft, quiet voice, she asked me "Where did you go to medical school?" I told her. "And where did you do residency?" I answered her again. "Do you enjoy being a doctor?" I told her yes, very much so. I wasn't sure if another interview was in my future, so I flipped the coin on her.
"Why do you ask, ma'am?" I questioned her. "Did you once work in the medical field?"
She shook her head. "No, I didn't. But my daughter was going to be a nurse." I waited for her to continue but she seemed absorbed in her memory. "What happened?" I finally asked, my curiosity peaked. "Unfortunately," Bertha answered, sadness sweeping across her face, "she wrecked her car late one night while driving home from a training shift and died. She was nineteen."
I grabbed Bertha's hand again and held it, humbly reminded that every face I encounter holds a story. And quite honestly, I could not even begin to imagine the pain that would come with losing a child. "I'm so sorry," I said, stroking the back of her hand.
"Don't be," she said, "I still had a wonderful life." She went on to explain that she had six children total, four of which were still alive but unfortunately not nearby geographically. This explained why she had been placed into a rehab unit from her assisted-living arrangement while recovering from pneumonia. "They are here, though," she said, lightly tapping her heart with her free hand.
After another pause, I had to ask my next question. "What happened to your other child?" "Oh," she answered thoughtfully, "we had a retarded son that died in adulthood. My husband and I managed to care for him at home until he passed." She went on to proudly explain that it was no small feat to raise a mentally-challenged child in earlier days--that most were institutionalized. "And your husband?" I asked. "Well, he and I were married for 53 years before he passed away. That was quite a few years ago. But, we managed to stay together and keep our love the whole time." We talked a few more minutes, her insightful words leaving a significant imprint upon me.
Finally, I finished my exam. Before leaving her, I thanked Bertha for her time and for sharing her life story with me. Happily, she did very well for us in the ER and was admitted to observation.
Just returning from my recent unplanned medical leave, I felt Bertha's story grab my shoulders and shake me. Not just shake me, but rattle my soul. My encounter with her was a well-timed reminder of just how privileged I was to be an emergency physician.
And suddenly, it dawned on me. I was the one who benefited most from the interview process with a patient. Sure, there is history-taking involved with my job, to find out the specifics of an illness that might help me provide the most focused and complete care to a patient. But this other "stuff," this personal information that a patient shares with me, isn't this more like an interview? I don't necessarily need to know everything a patient shares, but doesn't it all provide a much more complete picture of the person I am trying to help? And, besides, can't some of my patients' shared life experiences help me along my own life's journey?
A resounding yes and yes, if you ask me. I think I'm going to call the local news station and thank them for their meaningful segment...
As always, big thanks for reading. Also, a HUGE thank you to all the personal emails and posted comments from my last posting. Your warm welcomes and kind words are greatly appreciated. I have some of the coolest readers ever...
Of course, I was wrong. My following shift, I encountered an older, scholarly-looking gentleman who had presented to our department with complaints of acute abdominal pain. After introducing myself to both himself and his wife, I began to ask the patient important history questions when he suddenly interrupted me.
"Doctor," he asked, "before I agree to let you treat me, can you tell me where you went to medical school?" Although surprised, after watching the news segment just two days earlier, I anticipated that an encounter like this would eventually happen. "In Philadelphia," I answered. "And where in your class did you graduate?" "In the top ten percent," I replied. His questions kept coming. "And where did you complete your residency?" "Did you serve as chief resident your final year?" "How long have you been working in this emergency room?" As I patiently answered his questions, I began to wonder if the word "acute" was the right word to describe his abdominal pain.
Finally, though, he appeared satisfied with his interview. "Okay," he said, "I give you permission to treat me."
"Well, sir," I said, deciding to turn the tables on him, "I am not sure I want to treat you." I caught him off-guard. He looked inquisitively at me as I paused for good effect before continuing. "I have one question I want to ask you before I agree to treat you."
"Okay, Doctor," he said, "what is it?"
I took a deep breath and smiled as I spoke. "How will you be paying me for your visit today?" We both laughed. Regardless of his answer, he knew I would be his treating physician.
I hadn't thought about this encounter until just recently, after I had walked into Room 17 to introduce myself and examine a patient my resident was currently treating.
In the dimly-lit room, I found Bertha, alone without company, lying in a cot with hospital blankets pulled up to her chin. She was a 93 year-old woman sent to us from a local rehabilitation unit with complaints of chest pain. She had been placed there recently to recover from a bout of pneumonia. Bertha looked her age, appearing frail in size, her tiny body barely poking it's physicality into her covering sheets. Her face was graced with creviced wrinkles and framed with an unkempt gray bob. Her hazel eyes, however, belied her years. They were fierce and focused, guarded even, glistening with anticipation as I approached to introduce myself.
"Hello, ma'am," I said, reaching for her hand under her covers, "my name is Dr. Jim and I will be following your treatment today with Dr. Brad, one of our resident physicians who I am supervising."
She looked me carefully up and down as I continued. "Is your chest pain gone?" She nodded yes to my question. "Do you need anything right now?" She nodded no. "Is it okay, ma'am, if I listen to your heart and lungs?" She nodded yes.
I pulled my stethoscope from around my neck, placing it's diaphragm on her chest wall while inserting the listening buds into my ears. While bent over her and listening, I watched her face closely, appreciating her unique eyes. Suddenly, though, her lips moved. Unable to hear her, I stood up while removing the ear buds. "What is that, ma'am?" I asked.
With a soft, quiet voice, she asked me "Where did you go to medical school?" I told her. "And where did you do residency?" I answered her again. "Do you enjoy being a doctor?" I told her yes, very much so. I wasn't sure if another interview was in my future, so I flipped the coin on her.
"Why do you ask, ma'am?" I questioned her. "Did you once work in the medical field?"
She shook her head. "No, I didn't. But my daughter was going to be a nurse." I waited for her to continue but she seemed absorbed in her memory. "What happened?" I finally asked, my curiosity peaked. "Unfortunately," Bertha answered, sadness sweeping across her face, "she wrecked her car late one night while driving home from a training shift and died. She was nineteen."
I grabbed Bertha's hand again and held it, humbly reminded that every face I encounter holds a story. And quite honestly, I could not even begin to imagine the pain that would come with losing a child. "I'm so sorry," I said, stroking the back of her hand.
"Don't be," she said, "I still had a wonderful life." She went on to explain that she had six children total, four of which were still alive but unfortunately not nearby geographically. This explained why she had been placed into a rehab unit from her assisted-living arrangement while recovering from pneumonia. "They are here, though," she said, lightly tapping her heart with her free hand.
After another pause, I had to ask my next question. "What happened to your other child?" "Oh," she answered thoughtfully, "we had a retarded son that died in adulthood. My husband and I managed to care for him at home until he passed." She went on to proudly explain that it was no small feat to raise a mentally-challenged child in earlier days--that most were institutionalized. "And your husband?" I asked. "Well, he and I were married for 53 years before he passed away. That was quite a few years ago. But, we managed to stay together and keep our love the whole time." We talked a few more minutes, her insightful words leaving a significant imprint upon me.
Finally, I finished my exam. Before leaving her, I thanked Bertha for her time and for sharing her life story with me. Happily, she did very well for us in the ER and was admitted to observation.
Just returning from my recent unplanned medical leave, I felt Bertha's story grab my shoulders and shake me. Not just shake me, but rattle my soul. My encounter with her was a well-timed reminder of just how privileged I was to be an emergency physician.
And suddenly, it dawned on me. I was the one who benefited most from the interview process with a patient. Sure, there is history-taking involved with my job, to find out the specifics of an illness that might help me provide the most focused and complete care to a patient. But this other "stuff," this personal information that a patient shares with me, isn't this more like an interview? I don't necessarily need to know everything a patient shares, but doesn't it all provide a much more complete picture of the person I am trying to help? And, besides, can't some of my patients' shared life experiences help me along my own life's journey?
A resounding yes and yes, if you ask me. I think I'm going to call the local news station and thank them for their meaningful segment...
As always, big thanks for reading. Also, a HUGE thank you to all the personal emails and posted comments from my last posting. Your warm welcomes and kind words are greatly appreciated. I have some of the coolest readers ever...
Likelihoods and Badness
A patient the other day was caught in a typical EM dilemma.
39M with stuttering chest pain starting this evening, dull and mid-substernal radiating to the left arm without association to exercise, diaphoresis, or shortness of breath. The first episode lasted for 20 minutes then stopped abruptly, and then a second episode came on an hour after that with chest pain lasting continuously up until now. The kicker being that that second episode was associated with tingling of the left side of his face and felt like the arm was getting worse.
He had real acute neurological deficits: left face hypesthesia, left facial droop, left tricep and digit extensor deficits, left arm drift, and left leg drop (NIHSS:4). Despite her age and lack of risk factors, she was having a small stroke. So chest pain and possible CVA? Scan the chest of aortic dissection, particularly since he’s young and any real CVA would likely be from a paradoxical clot coming through the heart of starting within it, possibly from the aorta, or from the carotids.
The patient was in sinus rhythm, getting ASA and NTG and morphine ad lib, first troponin still pending. Didn’t even bother with a CXR to start.
At our hospital the Code Stroke policy is anyone with acute neurological deficiets within the past 8 hours gets protocolized, and the standard deal is stat labs and line, then prioritized non-con head CT, then CTA head and neck, and often a CT Perfusion of the head. On top of that we wanted to get a CTA of the chest for the concern of dissection.
The neuroligcal loss was real, but what about the chest pain? He’s young, had a TIMI score of 0, the pain really wasn’t that intense and he wasn’t really that uncomfortable, sort of overall giving the impression that this is not someone with aortic dissection, let alone cardiac chest pain at all. But still we needed to evaulate the chest pain, and imaging both his chest and head would require a lot of contrast dye, far more than we typically routinely safe.
I called the radiologists to talk about their imaging protocols, could they scan the arch and then follow the dye up through up the neck? Should it be vice versa? Is there any way around a double contrast load? If we had to sacrifice technical quality working up either the CVA or the aortic dissection, which would we want to give up?
The problem being that 1) giving the patient too much dye isn’t a good thing, but 2) making the diagnosis of an intra-cranial bleed or ischemic stroke is important, but even more so 3) despite the low pre-test probability of aortic dissection, an aortic dissection would kill him now, much quicker than a CVA.
What a balance: low-risk high-likelihood scenario pitted against a high-risk very-low-likelihood scenario.
Just another day in the ER.
The Cell Phone Sign
The Gist: An easy way to gauge the seriousness of a patient's illness - determine the patient's texting (or engagement in Facebook, Angry Birds, or Draw Something). The cell phone sign - the triage equivalent of the "Hamburger Sign" in appendicitis?
I suggest that medical students beginning their clerkships read a short, humorous piece in this month's Annals of Emergency Medicine entitled "It's This Texting Thing." The author codifies the observations we make regarding a patient's interactiveness into an easy rubric, scaled from 1-5, to assess the severity of an emergency department (ED) patient's ailment based on the patient's texting. For example, a patient who texts during the examination without looking up is awarded a 1 whereas a patient who is not texting at all gets a 5 (and very likely a body bag as the patient is probably actively exsanguinating or pulseless). A patient with a score of 3 is probably suffering a ailment of the following severity: cerebrovascular accident, diverticulitis, or perhaps a fracture. Sure, the article was probably partially written out of the frustration of extracting a history out of a patient glued to their device of choice and is placed in the journal for entertainment value . Funny. Simple. And, in my experience, fairly accurate.
Anecdotally, I can corroborate this rubric's predictive value, although I came to this conclusion in a more roundabout fashion. As a zealous medical student, I spent an "off day" during my first month of third year clerkships in the ED. I entered a patient's room in the ED and began with my routine introduction and history taking. The patient's "worst headache of her life" brought her to the ED. I took a stellar history and completed a thorough physical exam, although it was rather difficult at times, as she was engrossed in her Droid, playing Angry Birds or updating her Facebook status. I eagerly went to present to my attending. Before I began, my attending asked the crucial questions in the ED, "Well, is she sick or not sick? Is she staying or going home?" My attending then shared with me one of the keys to patient assessment in the ED. "Generally," she said, "you can figure that out within the first 30 seconds you see the patient." So true.
In the hundreds of patient encounters since that time, I've slowly developed skills in rapidly ascertaining a patient's overall status. Hopefully this will eventually translate into the sought-after clinical "gestalt." Generally, one only needs marginal common sense and observational skills - how eager they are for a sandwich, whether they are watching tv or fiddling with a phone, or the difference in pain perception when one is overtly palpating versus palpating through a stethoscope. Conversely, the absence of these types of behaviors in "tough guy" (or gal) patients have acted as clues that these patients were sicker than they let on. Regardless, observation of patient's non-verbal cues is an important part of patient assessment (and can be both frustrating and supremely entertaining).
References:
Svesko V. It's This Texting Thing. Annals of Emergency Medicine Volume 59, Issue 5 , Pages 438-439, May 2012
Anecdotally, I can corroborate this rubric's predictive value, although I came to this conclusion in a more roundabout fashion. As a zealous medical student, I spent an "off day" during my first month of third year clerkships in the ED. I entered a patient's room in the ED and began with my routine introduction and history taking. The patient's "worst headache of her life" brought her to the ED. I took a stellar history and completed a thorough physical exam, although it was rather difficult at times, as she was engrossed in her Droid, playing Angry Birds or updating her Facebook status. I eagerly went to present to my attending. Before I began, my attending asked the crucial questions in the ED, "Well, is she sick or not sick? Is she staying or going home?" My attending then shared with me one of the keys to patient assessment in the ED. "Generally," she said, "you can figure that out within the first 30 seconds you see the patient." So true.
In the hundreds of patient encounters since that time, I've slowly developed skills in rapidly ascertaining a patient's overall status. Hopefully this will eventually translate into the sought-after clinical "gestalt." Generally, one only needs marginal common sense and observational skills - how eager they are for a sandwich, whether they are watching tv or fiddling with a phone, or the difference in pain perception when one is overtly palpating versus palpating through a stethoscope. Conversely, the absence of these types of behaviors in "tough guy" (or gal) patients have acted as clues that these patients were sicker than they let on. Regardless, observation of patient's non-verbal cues is an important part of patient assessment (and can be both frustrating and supremely entertaining).
References:
Svesko V. It's This Texting Thing. Annals of Emergency Medicine Volume 59, Issue 5 , Pages 438-439, May 2012
The Cell Phone Sign
The Gist: An easy way to gauge the seriousness of a patient's illness - determine the patient's texting (or engagement in Facebook, Angry Birds, or Draw Something). The cell phone sign - the triage equivalent of the "Hamburger Sign" in appendicitis?
I suggest that medical students beginning their clerkships read a short, humorous piece in this month's Annals of Emergency Medicine entitled "It's This Texting Thing." The author codifies the observations we make regarding a patient's interactiveness into an easy rubric, scaled from 1-5, to assess the severity of an emergency department (ED) patient's ailment based on the patient's texting. For example, a patient who texts during the examination without looking up is awarded a 1 whereas a patient who is not texting at all gets a 5 (and very likely a body bag as the patient is probably actively exsanguinating or pulseless). A patient with a score of 3 is probably suffering a ailment of the following severity: cerebrovascular accident, diverticulitis, or perhaps a fracture. Sure, the article was probably partially written out of the frustration of extracting a history out of a patient glued to their device of choice and is placed in the journal for entertainment value . Funny. Simple. And, in my experience, fairly accurate.
Anecdotally, I can corroborate this rubric's predictive value, although I came to this conclusion in a more roundabout fashion. As a zealous medical student, I spent an "off day" during my first month of third year clerkships in the ED. I entered a patient's room in the ED and began with my routine introduction and history taking. The patient's "worst headache of her life" brought her to the ED. I took a stellar history and completed a thorough physical exam, although it was rather difficult at times, as she was engrossed in her Droid, playing Angry Birds or updating her Facebook status. I eagerly went to present to my attending. Before I began, my attending asked the crucial questions in the ED, "Well, is she sick or not sick? Is she staying or going home?" My attending then shared with me one of the keys to patient assessment in the ED. "Generally," she said, "you can figure that out within the first 30 seconds you see the patient." So true.
In the hundreds of patient encounters since that time, I've slowly developed skills in rapidly ascertaining a patient's overall status. Hopefully this will eventually translate into the sought-after clinical "gestalt." Generally, one only needs marginal common sense and observational skills - how eager they are for a sandwich, whether they are watching tv or fiddling with a phone, or the difference in pain perception when one is overtly palpating versus palpating through a stethoscope. Conversely, the absence of these types of behaviors in "tough guy" (or gal) patients have acted as clues that these patients were sicker than they let on. Regardless, observation of patient's non-verbal cues is an important part of patient assessment (and can be both frustrating and supremely entertaining).
References:
Svesko V. It's This Texting Thing. Annals of Emergency Medicine Volume 59, Issue 5 , Pages 438-439, May 2012
Anecdotally, I can corroborate this rubric's predictive value, although I came to this conclusion in a more roundabout fashion. As a zealous medical student, I spent an "off day" during my first month of third year clerkships in the ED. I entered a patient's room in the ED and began with my routine introduction and history taking. The patient's "worst headache of her life" brought her to the ED. I took a stellar history and completed a thorough physical exam, although it was rather difficult at times, as she was engrossed in her Droid, playing Angry Birds or updating her Facebook status. I eagerly went to present to my attending. Before I began, my attending asked the crucial questions in the ED, "Well, is she sick or not sick? Is she staying or going home?" My attending then shared with me one of the keys to patient assessment in the ED. "Generally," she said, "you can figure that out within the first 30 seconds you see the patient." So true.
In the hundreds of patient encounters since that time, I've slowly developed skills in rapidly ascertaining a patient's overall status. Hopefully this will eventually translate into the sought-after clinical "gestalt." Generally, one only needs marginal common sense and observational skills - how eager they are for a sandwich, whether they are watching tv or fiddling with a phone, or the difference in pain perception when one is overtly palpating versus palpating through a stethoscope. Conversely, the absence of these types of behaviors in "tough guy" (or gal) patients have acted as clues that these patients were sicker than they let on. Regardless, observation of patient's non-verbal cues is an important part of patient assessment (and can be both frustrating and supremely entertaining).
References:
Svesko V. It's This Texting Thing. Annals of Emergency Medicine Volume 59, Issue 5 , Pages 438-439, May 2012
A Guide to Intubating through the Intubating Laryngeal Airway by James DuCanto
James DuCanto just emailed me with a guide to intubating through LMAs. My first question, of course, is can I share it with the listeners, so…
Here is the guide
You just read the post: A Guide to Intubating through the Intubating Laryngeal Airway by James DuCanto from EMCrit Blog - Emergency Department Critical Care.
Good luck for the ACEM clinicals this weekend!
For those coming to Melbourne for the ACEM clinical exams this weekend, good luck!
The exams are being held in an outer suburban area of Melbourne, so the options for fine dining are a bit limited. If you're getting in to town a day or two early (as we strongly recommend) it'd be worth your while to catch a cab in to Chapel Street, WIndsor, and have a stroll around, there's loads of good restaurants there, or pick your favourite venue in the city and catch a train in.
You could also cab it in to StKilda, and I'd highly recommend going to Cicciolina on Acland Street. You can't book a table, but if you arrive early (before 6pm) you'll likely get a seat. Alternatively if you want to go a bit more upmarket, you can't go past Donovan's down on the waterfront. Great atmosphere, great food & wine.
If you'd rather stay local, and like asian food, I'd recommend going to The River Kwai, in Clayton (it's just down the road from Monash Medical Centre). It's a great Thai & Burmese restaurant, but is very busy, so make sure you book.
If you need any tips on Melbourne this week/weekend feel free to drop me a line, and I'll be helping out at the short & long cases on Saturday (at Moorabbin), so may see you there!
The exams are being held in an outer suburban area of Melbourne, so the options for fine dining are a bit limited. If you're getting in to town a day or two early (as we strongly recommend) it'd be worth your while to catch a cab in to Chapel Street, WIndsor, and have a stroll around, there's loads of good restaurants there, or pick your favourite venue in the city and catch a train in.
You could also cab it in to StKilda, and I'd highly recommend going to Cicciolina on Acland Street. You can't book a table, but if you arrive early (before 6pm) you'll likely get a seat. Alternatively if you want to go a bit more upmarket, you can't go past Donovan's down on the waterfront. Great atmosphere, great food & wine.
If you'd rather stay local, and like asian food, I'd recommend going to The River Kwai, in Clayton (it's just down the road from Monash Medical Centre). It's a great Thai & Burmese restaurant, but is very busy, so make sure you book.
If you need any tips on Melbourne this week/weekend feel free to drop me a line, and I'll be helping out at the short & long cases on Saturday (at Moorabbin), so may see you there!
Severe Pelvic Trauma
Hemodynamically unstable pelvic fractures are a talk-and-die situation. These folks require aggressive, rapid treatment if they are going to survive the injury. Inspired by my mentor, Thomas Scalea, I discuss the management of the unstable pelvic trauma patient.
Read these Incredible Posts by Chris Nickson
Young-Burgess Shock Trauma Pelvic Fracture Classification
(J Trauma 30(7): 848-856)
from the handbook of fractures
Open Iliac Artery Clamping
Dubose and Inaba (J Trauma. 2010;69: 1507?1514)
How to Kill when Intubating
Forgot to mention on the podcast–The combination of an open-book pelvis that you have not bound yet and paralytics is a great way to cause massive bleeding. Bind the open pelvis before tubing!!!
New East Pelvic Trauma Guidelines
(J Trauma 2011;71(6):1850)
- external fixation doesn't limit blood loss, but reduces fracture displacement (III)
- unstable patients should get angio (I)
- pts with blush may require angio even if stable (I)
- ongoing bleeding after angio should get repeat angio (II)
- >60 y/o with major fx should get angio even if stable (II)
- anterior fxs assoc with ant vessel injury and posterior = posterior (III)
- Bilateral non-selective is safe, gluteal ischemia is more likely from injury not angio (III)
- And doesn't affect male potency (III)
- FAST is insensitive in pelvic trauma (I)-don't agree with this one
- Adequate Specificity (I)
- DPA is test of choice (II)
- Use CT if stable (II)
- Fracture pattern doesn't predict need for angio (II)
- Nor hematoma location (II)
- Absence of ICE doesn't exclude active hemorrhage (II)
- Volume > 500 cm3 predicts need for angio (III)
- Isolated acetabular fx may still need angio (III)
- Perform cystogram after ct (III)
- Binders reduce fx as well as definitive stabilization and decrease pelvic volume (III)
- And they limit hemorrhage (III)
- They work as well or better than external fixation in controlling hemorrhage (III)
- RetroP Packing can be used to salvage after failed angio (III)
- Can be used as primary in an integrated protocol (III)
You just read the post: Severe Pelvic Trauma from EMCrit Blog - Emergency Department Critical Care.
Episode 26 – Ocular Ultrasound with Chris Fox
So we just finished maybe the most amazing week of our lives (besides our wedding and babies’ birth – We love you wives if you’re reading this!) Castlefest is over, and we’ve got some special Castlefest footage for you. Chris Fox is coming into your earbuds this month to teach you about Ocular ultrasound. And yes, I know Castlefest has just ended, but we don’t like to live in the past.
…We’ve got a special announcement today… ALASKAFEST 2012! I’d tell you about it right now, but why don’t you just watch the episode and we explain everything fully at the end. We’ve got room for about 1/4th (25% in old money) of the people we had at Castlefest, so don’t get mad at us if it’s full. Registration is open now.
p.s. – audio for this episode isn’t perfect as it’s recorded from a lapel mic at Castlefest, but it’s Chris Fox people, so quit your complaining…….
The post Episode 26 – Ocular Ultrasound with Chris Fox appeared first on Ultrasound Podcast.
Bougie vs stylet
Brazil, Grobler, Greenslade and Burke have published a comparison of intubation performance on Laerdal mannequins ("part-task trainers") using either a Gum-Elastic Bougie (GEB) or re-inforcing stylet (introducer) ...
Happiness Is…
An outstanding sunset on a quiet beach.
A flatmate who can easily be persuaded to throw down the study books and head to said beach.
The ability to land a one-armed cartwheel despite my advancing age.
The postman arriving this morning with my handbag and all its precious (to me!) contents, including cash, electronics, documents, cards, etc.
The last few days, a little better than the preceding weeks, to be sure.
