ECG of the Week – 5th May 2014

This ECG is from a 70 yr old male who presented complaining of palpitations for the last few hours. I don't have any further clinical history on the case, sorry.




Click to enlarge

VAQ Corner

A 70 yr old male presents to your Emergency Department complaining of palpitations, onset a few hours ago.
Vital signs: BP 125/82  RR 20 T 37.0 Sats 96% RA
  • Describe and interpret his ECG (70%)
  • Outline your management options (30%)


Dengue in Fiji, lessons for home.

It was a Saturday night during festival season and we were the only Emergency Department in town. When I walked in we were completely full, with three-fourths of the patients waiting for a bed in the wards. There were only two nurses and two physicians. At 4 AM, the triage nurse left her post. With no one guarding the waiting room, checking vital signs, and explaining the process, we were bombarded.

The hospital and outlying health centers were full, and we were the final stop. Patients, each accompanied by at least three family members, stormed the ED hall, demanding to be seen. We were forced to use benches and makeshift wheelchairs to evaluate a range of complaints – an open boxers fracture, abdominal pain, febrile illness, chest pain, car accidents. This is an all too familiar scene, but this time it was different. The entire emergency department was already jam-packed with men and women, young and old, Indian and Fijian, each one in seemingly a different stage of an identical illness.

I have just returned from a global health elective in Fiji, where I worked as a physician in the Accident & Emergency (A&E) Department of the capital’s Colonial War Memorial (CWM) Hospital. My time there coincided with an unprecedented dengue outbreak, and the health care system was quickly overwhelmed. The situation required an improvised “Dengue Contingency Plan.”

Screen Shot 2014-04-30 at 17.58.51As critical saturation was reached at CWM, the physicians and hospital administrators were challenged with implementing a literature-based strategy to help direct management of dengue patients. Though there is no approved vaccine and treatment is largely supportive, organizations such as the W.H.O. and the Sri Lankan Ministry of Health have published guidelines on patient monitoring and admission criteria. A literature review revealed clinical predictors of poor outcomes. Nearly all of the patients we saw in the ED met admission criteria based on clinical status, lab values, and expected course. Keeping all of these patients in the hospital, however, would saturate the hospital’s ability to care for the ill and functionally shut it down. As is often the case back home, clinical guidelines cannot always be applied to individual patients. Policies adopted from foreign countries with their unique pathologies, resources, and practice patters may not adequately address local problems.

While the recent arc of global health has concentrated on non-communicable disease, emerging tropical diseases continue to surprise us back home. I imagine most of these diseases will be misdiagnosed in the early stages.

I work in a hospital with a large immigrant population near an international airport, where every headache could be neurocysticercosis, every pneumonia could be tuberculosis, and every biliary colic could be amoebic liver abscess. Last year alone, southern Texas saw dozens of confirmed dengue cases. I wonder how many of these were initially diagnosed with acute viral illness or aseptic meningitis after lumbar puncture. Identifying emerging threats requires a high index of suspicion, yet physicians may have filed away diseases learned in medical school as pathologies we never thought were going to happen in our backyard.

Dr. Sarah Dendy is an Emergency Medicine trainee writing about her work in Fiji with the University of Texas Medical School at Houston Department of Emergency Medicine Global Health Program.

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Is the KUB dead?

Before CT abdomen became commonplace in the ED, a plain radiograph of the abdomen (KUB for Kidneys, Ureters, and Bladder) was often a screening for kidney stone.  Currently, ultrasound and CT abdomen are used quite often to diagnose ureterolithiasis as they offer much more information.  Is the KUB dead?

The answer is no.  KUB still has a place particularly in monitoring the progress of known kidney stones.  I personally use them for repeat customers to assess progress (or more often prove to urology that they have not progressed).  Helpful hint:  if a patient is presenting for a second ED visit for kidney stone pain, check their scout film if they had a prior CT.  If you can see the stone on scout film, you can definitely re-image the patient with a KUB to reevaluate the location of the stone.  Here is an image of an 8mm stone in the upper right ureter (lateral to L3)  as seen on KUB:

KUB stone

This patient has an 8mm stone and presented to the ED with failed outpatient management.  The stone hadn’t moved from a prior CT scan after 1 week of symptoms.  Urology elected to take the patient to the OR for operative management. 

Please comment if you have another good use of the KUB in the ED. 

Author:  Russell Jones, MD

 


Filed under: Abdomen XR, Abdomen/Pelvis, Genitourinary, Non-Trauma, XR Tagged: Nephrolithiasis

What makes a good clinical educator?

apple ExpertPeerReviewStamp2x200In this constantly evolving world of learner competencies, assessments, and milestones often is forgotten the important role of clinical teachers. We can all remember clinical instructors that stand out despite the grueling years of medical school and residency training. We admired them for various reasons and remember the insights and teaching pearls they bestowed upon us. But what exactly were the qualities that they possessed that other instructors did not have? What exactly did they have that made them a good clinical teacher in medicine?

Good Clinical Educator

The authors of the 2008 Academic Medicine paper “What makes a good clinical teacher?” (free PDF of article) wanted to know exactly that [1]. And so they did a qualitative analysis of 68 articles, essays, and public addresses published from 1909-2006 . Surprisingly, they found that those qualities listed more often were noncognitive skills although cognitive skills were definitely highly considered.

Noncognitive skills were defined as relationship skills, emotional states, and personality types. Examples of this included those instructors who were inspiring and motivating – encouraging learners to be the best that they could be. Cognitive skills were defined as those involving perception, memory, judgment, reasoning, and procedural skills. An example would be good medical decision making for patients with chest pain.

The most common themes the authors found to be present in good clinical teachers in medicine included:

  1. Medical / clinical knowledge
  2. Clinical and technical skills / competence, clinical reasoning
  3. Positive relationships with students and supportive learning environment
  4. Communication skills
  5. Enthusiasm

The authors best summarized their findings as

“excellent teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students”.

The authors conclude there must be a recognition of the importance of noncognitive skills in those who want to improve as clinical educators. Although the medical knowledge is important, that is merely the standard by which all educators must have. But to excel requires inspiring and motivating.

What are your thoughts regarding this paper? Think back to those educators that you had that made a lasting impact? What was it about them that made them so special? Do you agree with this list of attributes above? Or do you have anything that you would add or detract?

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
- Maya Angelou

Expert Peer Review

April 27, 2014

Outstanding clinical instruction is vital to a learner’s growth and development. Many qualities of outstanding instructors, identified in Sutkin’s article [1] and elsewhere [2-4], help educators in or outside the emergency department be successful. Didactic sessions and lectures in a conference room or auditorium, simulation, journal club, or podcasts are better with great instructors. Bedside teaching offers one venue for emergency physician educators. Despite knowing that good clinicians aren’t always great instructors, Niki labeled Sutkin’s downloadable PDF article as “Good clinician”

Where teaching takes place, its purpose and the audience matter. Formal teaching rounds by internal medicine faculty in a conference room to a team of learners at various levels without interruption rarely matches the style of, and opportunities for, teaching in the ED. Mandatory morning lectures to tired, hungry, distracted, or disinterested residents provide teaching opportunities without interruption, but infrequently deliver content in a manner that fosters integration and retention [5-10].

Bedside teaching is not without problems too. One example occurs when a learner presents a patient and the instructor focuses on the neurologic examination rather than the organ system responsible for the patient’s condition. The instructor may be an expert in neurology, therefore preferring to direct all learning towards his strength. This affords him comfort, and allows him to demonstrate his expertise. If you were to ask the instructor whether or not his teaching was effective, his answer would be an emphatic “yes.” Sadly, however, what the learner needed was teaching about the GI and cardiac systems responsible for the patient’s symptoms. The learner likely didn’t appreciate the instructor’s neurology expertise at that moment. Consequently, the learner considers the teaching to be poor.

As instructors, we must pay attention to our lesson, its appropriateness for the situation, and to the learner (and therefore, the patient). Furthermore, learners are better able to apply material that is relevant to their current educational demands, and are therefore more likely to retain this knowledge over time. Focused teaching creates a better “result” from their perspective.

Outstanding instruction requires practice. It requires a strong (not encyclopedic) fund of knowledge. Often individuals who know “everything” about a topic are not good teachers because they fail to translate their knowledge in a manner that allows learners to integrate new facts, skills, and reasoning abilities into something they not only can recall, but also apply. These shape the competencies, proficiencies, and milestones getting so much attention.

The key is to approach teaching in ways that acknowledge both the learner and the context. Most agree that poor teaching is better than no teaching. Yet outstanding instruction requires passion, commitment, integrity, and strong noncognitive skills. It should go without saying that making stuff up is never a good idea, may be dangerous, and can result in a teacher losing credibility rather than impressing learners.

Good listening skills are important to good clinical teaching because they allow an instructor to discover what learners desire to learn, how they think, and how much they truly understand. As instructors, we can engage learners by asking questions, soliciting input, and identifying whether or not they understand our message. It always helps me to remember that the success of learners equates to successful instruction.

Good teachers remember to teach to learners, not at them. They make their content interesting and teach with enthusiasm. They don’t focus only on their own strengths, but also on their learners’ needs. Our patients provide plenty of wonderful material for teaching. All patients have a story. These stories (some more interesting than others) offer instructors “teachable moments.”

Many terrific resources exist about clinical teaching [11-19].Here are a few pearls:

  • Adapt teaching to your audience, the environment, and the context
  • Teach to (or with) your learners, not at them
  • Be patient
  • Have a plan
  • Listen well and ask questions to engage your learners
  • Be as prepared as possible whenever possible
  • Limit the number of key messages
  • Admit what you don’t know and be comfortable looking things up
  • Demonstrate sensitivity to, and respect for, your learners and their time
  • Take advantage of a teachable moment

These pearls should help teachers be better. You know what? These qualities are similar to the qualities that make a good clinician. Maybe Niki was right.

Gus Garmel, MD FACEP FAAEM, Clinical Professor (Affiliate) of Surgery (EM), Stanford University School of Medicine, Former Co-Director, Stanford/Kaiser EM Residency Program, Senior EM Faculty, TPMG, Kaiser Santa Clara, CA, Consultant to Regional GME, Kaiser Northern CA, Oakland, CA, Senior Editor, The Permanente Journal, Portland, OR

 

References

  1. Sutkin G, Wagner E, Harris I, Schiffer R. What Makes a Good Clinical Teacher in Medicine? A Review of the Literature. Acad Med 2008;83:452-66.
  2. Wright SM, Kern DE, Kolodner K, et al. Attributes of Excellent Attending-Physician Role Models. New Engl J Med 1998;339:1986-93.
  3. Avegno J, DeBlieux PMC. Characteristics of Great Teachers. In Practical Teaching in Emergency Medicine. Rogers RL (ed). Wiley-Blackwell. UK. 2013:285-94.
  4. Bandiera G, Lee S, Tiberius R. Creating Effective Learning in Today’s Emergency Departments: How Accomplished Teachers Get it Done. Ann Emerg Med 2005;45:253-61.
  5. Be a Great Speaker (pt 1/5) from ALiEM
  6. Be a Great Speaker (pt 2/5) from ALiEM
  7. Be a Great Speaker (pt 3/5) from ALiEM
  8. Be a Great Speaker (pt 4/5) from ALiEM
  9. Be a Great Speaker (pt 5/5) from ALiEM
  10. Kerr C. Death by Powerpoint: How to Avoid Killing your Presentation and Sucking the Life out of your Audience. ExecuProv Press. Santa Ana, CA. 2001.
  11. Skeff KM, Stratos GA, Mygdal W, et al. Faculty Development: A Resource for Clinical Teachers. J Gen Intern Med 1997; 12(Suppl 2):S56-S63.
  12. Skeff KM, Stratos GA. Methods for Teaching Medicine. ACP Press. Philadelphia, PA. 2010.
  13. Shulman LS, Hutchings P. The Wisdom of Practice: Essays on Teaching, Learning, and Learning to Teach. Wilson SM (ed). Jossey-Bass. San Francisco, CA. 2004.
  14. Ende J. Theory and Practice of Teaching Medicine. ACP Press. Philadelphia, PA. 2010.
  15. Guth TA. Resident as Educator: A Guidebook Written by Residents for Residents. EMRA. Irving, TX. 2013.
  16. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform in Medical School and Residency. Jossey-Bass, San Francisco, CA. 2010.
  17. Kelly SP, Shapiro H, Woodruff M, et al. The Effects of Clinical Workload on Teaching in the Emergency Department. Acad Emerg Med 2007;14:526-31.
  18. Thurgur L, Bandiera G, Lee S, Tiberius R. What do Emergency Medicine Learners Want from their Teachers? A Multicenter Focus Group Analysis. Acad Emerg Med 2005;12:856-61.
  19. Whitman N, Schwenk TL. The Physician as Teacher, 2nd ed. Whitman Associates. 2007.

 

 

Author information

Nikita Joshi, MD
Nikita Joshi, MD
ALiEM Associate Editor
Editorial Board Member
Academic Fellow
Stanford University, Division of Emergency Medicine

The post What makes a good clinical educator? appeared first on ALiEM.

ST Elevation: is it due to old MI (LV aneurysm) or to acute STEMI?

A middle aged male was resuscitated from cardiac arrest (ventricular fibrillation).  Here is his initial ECG.  He was hypotensive.
Besides the Atrial Fibrillation, what do you think?











There is a slightly wide QRS, at 115 ms (by the computer).   It is not quite a bundle branch block, but rather a nonspecific intraventricular conduction delay (IVCD).  There are QS-waves in V3 and V4, and a QR-wave in V6.   There is some minimal ST elevation in V4 and V5, but in V4 it is not excessively discordant (if we can apply modified Sgarbossa rules even in nonspecific intraventricular conduction delay) and in V5 it is not concordant to the majority of the QRS, nor is it excessively discordant.

He underwent synchronized cardioversion into sinus rhythm, after which his blood pressure normalized.   Then had the following ECG recorded:
What do you think?


Analysis

The QRS is 116 ms.  It looks like IVCD with left ventricular aneurysm morphology.  Is it:
1. Simply persistent ST elevation after old MI (LV aneurysm morphology)?  
2. Acute STEMI?  
3. Subacute STEMI?  
4. LV aneurysm with acute STEMI superimposed?  

This is not at all an academic question: Both LV aneurysm and acute STEMI can cause VF arrest.

Hint: The ST elevation in V4 and V5, and the T-wave amplitude, appear to be too great for simple persistent ST elevation.


Is there a way to differentiate anterior LV aneurysm morphology from acute anterior STEMI?

Yes.  We have derived and validated (abstract in press) two similar formulas with moderate accuracy (85-87%), with sensitivity for acute STEM of about 90% and specificity of about 70%.   We also showed that they are more specific than another rule that uses QRS fragmentation.  The two formulas rely on the fact that acute STEMI not only has ST elevation, but has a prominent T-wave.

Rule 1: if there is any T-wave to QRS amplitude ratio among leads V1-V4 that is greater than 0.36, then it is likely to be acute STEMI.

Rule 2: if the sum of T-wave amplitudes in V1-V4 divided by the sum of QRS amplitudes in V1-V4 is greater than 0.22, then it is likely to be STEMI, not LVA

Outcome

The patient was cooled and taken to the cath lab.  There, a long acute mid-LAD 95% lesion with thrombus and low flow was seen and opened and stented.  There was also complex 3-vessel disease but the acute lesion was in the LAD.

Subsequently, records from another hospital revealed that he had a history of ischemic cardiomyopathy and of LV aneurysm with LV thrombus.  The thrombus had since resolved.

Here is the post-cath ECG:
The T-wave amplitude is diminished, and the ST elevation is also diminished. 
Now apply the rules:
Rule 1: V2 has 16.5/18.5 = 0.35, which is less than 0.36
Rule 2: (1.5 + 6.5 + 4 + 1) divided by (14.5 + 21.5 + 20.5 + 5 = 13/61.5 = 0.21 which is less than 0.22

The ECG thus supports the diagnosis of LV aneurysm now that the acute STEMI is resolved.


Formal echocardiogram confirmed dyskinesis (aneurysm) of the distal septum and apex.  EF was 16%.  Peak troponin I was 22 ng/mL.

Diagnosis:

LV aneurysm with superimposed acute STEMI.