#FOAMed Review 36th Edition

Welcome to the thirty-sixth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed. 

STANDARDIZING RSI [PAPER]: Great review looking at the key components to a safe and effective approach to RSI with useful algorithms and pictorial guides. 

ENDOTRACHEAL TUBE CONFIRMATION [BLOG]: ALiEM with a guide to proper technique for confirming endotracheal intubation using ultrasound with excellent images of US signs to be aware of.

THE BLOODY LUMBAR PUNCTURE [BLOG]: Perry et all with a new data analysis to evaluate a cutoff RBC count to differentiate SAH from a traumatic tap.

HEMODYNAMIC ACCESS FOR CRASHING PATIENTS [BLOG]: Josh Farkas discussed the femoral dual arteriovenous access technique in the critical patient and why it may be a useful approach. Pulm Crit 

More FOAMed. 


FEEDING ME SOFTLY [BLOG]: Working in an urban area, we may not deal with nutritional deficiencies too frequently but you may want to be aware of refeeding syndrome in your chronic alcoholic or anorexic patient. Broome Docs 


SKIN & SKIN STRUCTURE INFECTIONS [PODCAST]: FOAMCAST brings us a succinct discussion on abscess/cellulitis management with the up to date IDSA guidelines and hits on some hot topics in the dermatology world that everyone should know about!  


THE CRITICALLY ILL PREGNANT PATIENT [BLOG]: Excellent lecture from EEM 2014 by Dr. Haney Mallemat on the key differences in management of the critically ill pregnant patient. Remeber TOLD. Hippo EM 


RETROPERITONEAL HEMATOMA [BLOG]: A quick reminder on the RP bleed, what history should concern us, what physical exam findings we should be looking for, diagnosis, and more @ EM Docs.  

See you next week


Where is the love? Engaging students in research and critical appraisal

Editor’s Note: This is the third in a series of BoringEM research week posts. Dr. Murray is an editor at BoringEM and an expert at teaching medical students about research and the art of critical appraisal. She has been at the helm of designing and implementing a critical appraisal and research curriculum for the undergraduate medical students at Queen’s University. The graduated curriculum spans all four years and sets students up with a strong foundation in both evidence-based medicine and basic research skills. In this post Dr. Murray provides insight about how she stays on top of new evidence and how she uses it to at the point of care to provide the best care for patients. She also provides a few tips for students looking to get started

  – EP


I start my first class of the year: “Hi everyone – I’m Dr. Murray. I’m an emergency doctor.” The first RESEarc memeyear medical class perks up at the mention of emergency doctoring.  “And my job in the medical school is to teach you guys the skills for effectively reading published evidence and for producing your own research.” When the word “research” hits their ears, the computer screens suddenly get new attention, windows on Facebook and Twitter are surreptitiously opened and interest fades.

Why does the mere mention of “research” elicit moans of despair from otherwise bright, engaged students? Ground-breaking clinical trials and medical advances are constantly changing the way we practice medicine and furthering our understanding of human illness and recovery. Becoming an educated consumer of research is an essential part of becoming an effective clinician, even if your career aspirations don’t involve any kind of research creation. No modern day clinician can provide high quality medical care without a good approach to finding valid information for day-to-day questions. And yet I’m struggling for engagement, turning cartwheels in the front of the classroom in order to keep the attention focused on the critical appraisal task at hand.

Below are three common research-related issues that face doctors at all stages of medical training and practice. The undergraduate critical appraisal and research curriculum at Queen’s targets each of these three key questions to set a strong foundation for future practice. Below each question I have provided some tips that should be useful, regardless of stage of training.

How do I learn how to read and understand published research?

Few of us pick up the latest trial on hemodynamic monitoring or infection control or subarachnoid hemorrhage to read as the relaxing antidote to a challenging day. The concepts are often complex, the statistical tests have long names and are unfamiliar or incomprehensible, and it takes a lot of mental effort to see the paper through to its conclusion. You want to stay up to date but how can you get good at reading these things, let alone at identifying weak spots?

In this, as in all things, practice makes perfect. In order to get good at reading the literature, you have to read the literature. Don’t be intimidated! In our critical appraisal activities at Queen’s, students work in groups to appraise papers and then practice applying the evidence to relevant patient cases. Students each bring something unique to the table and have a different perspective on the analysis and implications, stimulating rich classroom discussions. Your experience with consuming evidence should be no different and the FOAM community is here to help you. There are a multitude of different online resources, ranging from overviews of the latest and best research to guided deep dives into selected papers. In fact, there are so many excellent options, I had a hard time limiting my recommended list of samplers to these:Richard Lehman writes a weekly blog for the BMJ summarizing the week’s best papers from NEJM, JAMA, BMJ, the Lancet, and Annals of Internal Medicine. Scan the blog and his pithy take home messages and entertaining commentary will guide you to the best research of the week.

  • Richard Lehman writes a weekly blog for the BMJ summarizing the week’s best papers from NEJM, JAMA, BMJ, the Lancet, and Annals of Internal Medicine. Scan the blog and his pithy take home messages and entertaining commentary will guide you to the best research of the week.
  • Ryan Radecki is an emergency physician who posts overviews and commentary on recent research relevant to emergency physicians in his blog Emergency Medicine Literature of Note. His near-daily updates and brief take-home messages will help you keep on top of the specialty.
  • The folks at The Bottom Line will walk you through the details of the important critical care trials step by step using a standardized template and a clear take home message. Their searchable index is an incredible gateway to a huge collection of important research.
  • Annals of Emergency Medicine has a journal club feature offering a series of structured review questions (tagged novice, intermediate or advanced) for readers to use as they appraise the selected article. The answers are published in a later issue, but many of the previous versions are available online now and can be incorporated into student or resident journal clubs for discussion.
  • Research and Reviews from Life in the Fast Lane. A collection of papers that include new and re-discovered research, this is a treasure trove of pre-appraised papers classified by relevance using a unique, awesome tagging system. (The only thing that could make this blog better is if the impressive list of international contributors included some of our impressive Canadian EM researchers… but I digress).
  • Speaking of Canadians, Dr. Ken Milne runs a podcast called The Skeptic’s Guide to Emergency Medicine that features a weekly review of recent cutting edge evidence, critiqued using the BEEM (Best Evidence Emergency Medicine) template, and always involving some cheesy 80’s music. Enhance your research skills while you exercise, commute or just chill on the couch.

These are just the tip of the iceberg, but are some good places to get started. The FOAM world is friendly and inclusive, and no one will snub you for not knowing the difference between a T-test and a one way Analysis of Variance. Join the discussion!

How do I find specific research to answer my patient’s immediate problem?

You have a patient with a clinical problem to which you don’t know the answer.  Your quick online literature search brings up 8000 hits and every clinician you ask has a different answer to your question. How can you get your hands on reliable evidence quickly? And yes, you have a paid subscription to UpToDate, but don’t you want to be a little more sophisticated?!  In the clinical years our medical students are required to complete an assignments in each rotation where they briefly review the literature on a clinically relevant question, formulated while caring for patients. It is during clerkship that they start to understand that applying the best available evidence to a specific patient context is what the art of EBM is all about.

Once again, the FOAM world is here to help you answer your clinical questions. I’ll highlight the TRIP Database. “TRIP” stands for “Turning Research into Practice.” Their motto is “find research fast” and it is a super place to go for this exact purpose. Enter a query using either the basic or more advanced search functions and the results come out colour-coded.

Green is for evidence summaries (systematic reviews and practice guidelines), red for key primary research and so on, all the way down to yellow for e-textbooks. It’s a nice way to find collections of pre-appraised evidence like Best Bets,  and sometimes someone has asked the very question you are looking for. It taps into Cochrane as well as a variety of other sources – check it out the next time you have a clinical question.


How can I get started doing my own research?

At Queen’s we group students with a clinician-scientist mentor in a 3:1 ratio during a course that spans the second (pre-clinical) year. Guided by the mentor, students complete a series of structured assignments, which culminate in the development of research proposal. Many students go on to carry out their proposal during the summer, and the course deadlines are aligned with funding application deadlines in order to facilitate this. Sometimes I get pushback about this part of the curriculum. If I had a dollar for every medical student or resident who has told me that they already know how to do research and shouldn’t have to do any more… well, I’d have a lot of dollars.

The reality is that every time you involve yourself in a research project, you reap additional benefits that have nothing to do with the actual research results. Successfully taking a research project from start to finish requires persistence and determination, and makes you a much better consumer of published work as a result. Engaging in clinical practice research gives you the opportunity to become intimately familiar with a clinical area and the nuances and questions specific to that topic. It enables you to look closely at local practices (and regionally or nationally if your research is multi-centre) and identify areas where patient care can be improved. It allows you to form relationships with others involved in the same research area, including faculty mentors, colleagues and non-physician collaborators. Completed research projects on your cv are career-enhancing, opening doors and creating opportunities – and the dose-response curve is impressive. More completed projects lead to more knowledge, connections and professional opportunities, as well as improving your care and the care environment in which you work.

challenge accepted

So, take the first step: Study something that bugs you. Maybe you are horrified by the amount of garbage generated in a single ED visit. Perhaps you have seen 10 different ED doctors in the same centre use 10 different doses of GTN for acute pulmonary edema. Possibly you have wondered why every single patient with an arrhythmia gets a chest Xray during his or her ED visit. Here is an opportunity to educate yourself and use your research to try to improve care in your own local venue. Check out the posts this week on Boring EM’s research week to find resources and learn about the research process. Start with a systematic review of the literature, and find out what is already there. Make it your thing – do a presentation on it, and use your newfound knowledge to educate others. Create patient information packages. Do an education session for your nursing colleagues. Make connections with local practitioners and researchers to develop a research proposal to evaluate some aspect of your work. Find a mentor who is active in this area or interested in the topic (ideally both). And along the way, don’t forget to share your work on one of the many FOAM sites that encourage international input and dialogue.

How do you stay on top of the literature? What blogs or websites do you use to stay on top of recent advances or to look at important papers in-depth? Do you have any tips for engaging medical trainees on the topic of critical appraisal and research?
Share your thoughts below.

Author information

Heather Murray
Heather Murray
Emergency Physician and Medical Educator at Queen's University
Dr. Murray has a special interest in Evidence-based Medicine, research methods and diagnostic reasoning

The post Where is the love? Engaging students in research and critical appraisal appeared first on BoringEM and was written by Heather Murray.

Healthcare Update Satellite — 03-04-2015

Homeless North Carolina VA patient comes into the ED to be evaluated for the sores on his feet. His shoes are falling apart. Nurse Chuck Maulden bandages up the patient’s feet and then gives the patient the brand new Nike sneakers off of his own feet. Chuck then works the rest of his shift in a pair of shoe covers and doesn’t say anything about it. Only way that people found out was because the patient’s family called to say thank you. We need more people like Chuck.

I’m not aware of too many uses for virtual reality in medicine, but this seems to be a good one: seeing what it’s like to suffer from schizophrenia. Imagine being cooped up in an elevator with strangers staring at you and voices telling you “you will fail”. The author of the article wore the VR headset only briefly, but noted that after he removed the headset, “the feeling of discomfort lingered.”

Long Island woman fights to keep database about NY physicians online. It is scheduled to go offline due to lack of funding. “Choosing someone because they were nice just didn’t work anymore.” Just think, you can always rely upon the accurate and reliable data from Press Ganey and Healthgrades.com. /sarcasm.

Long Island town demanding that nearby hospital construct an emergency department in its town. Hurricane Sandy destroyed the prior hospital in 2012. Commenter to the article notes “Everyone wants the luxury and availability of a hospital but fails to support it financially. Don’t be like Long Beach or your hospital will also be Long Gone.”
Spot on, ma’am. Spot on.

I suppose this explains why I never see any parents of newborn children coming to the emergency department with strokes. Sleeping more than 8 hours per night associated with almost a 50% increase in stroke risk.

Woman complains to TV station because Florida’s Gulf Coast Medical Center emergency department is close to maximum capacity, and her 87 year old father had to sleep in the hallway. News flash, lady: Emergency departments are crowded all over the country. However, Florida doesn’t have enough doctors because of the miserable environment Florida has created for its medical providers. Remember the amendment to Florida’s Constitution revoking the licenses of doctors who had three malpractice cases against them? You reap what you sow.

California hospital’s emergency department volume up 7% after Obamacare implementation. Our hospital’s ED volume is up 15%. According the article, Obamacare advocates say that ED numbers would decrease once people received insurance. Now they’re walking it back, citing studies that the decrease in emergency department use only begins to show up at 1 year after insurance enrollment. They’ll be sure to measure and report on the new numbers … just after the next election.

Patients gone wild. Louisiana’s own Patricia Munzey arrested and charged with assault and battery of emergency personnel after she threatened to “slap and kill” ED staff and then kicked a nurse in the face when she was trying to bandage the patient’s injury.

More patients gone wild. Pennsylvania patient William Whitmoyer gets brought to emergency department and threatens to come back to hospital with gun and “make hamburger meat” out of everyone in Geisinger Medical Center. Upset over administrator making $5.6 million. Because the threat of violence caused alarm and was an inconvenience to staff, he was arrested and charged with disorderly conduct and with making terroristic threats.

Quite an interesting idea circulating on Reddit: People waiting in the emergency department for a someone else to be treated should be encouraged to donate blood.

Interesting infographic on the shelf life of multiple foods. According to the comments, though, it seems to create more questions than it answers. Some people are claiming that eggs can be left out on a shelf for a year without spoiling if they aren’t washed. Not sure I’d be the first to try a year old omelette.

Lung-RADS launches: New system for lung cancer screening chest CTs

The American College of Radiology has started implementing its new system for risk-stratifying the findings on low dose chest CTs performed for lung cancer screening. The ACR's new system is called Lung-RADS™, and it emulates the ACR's familiar Bi-RADS's 0-4 scoring system for mammography: Lung-RADS 0: Incomplete, meaning previous chest CTs are still being located [... read more]

The post Lung-RADS launches: New system for lung cancer screening chest CTs appeared first on PulmCCM.

Weakness and Dyspnea with a Sine Wave. It’s not what you think!

I don't have all the clinical data on this patient, and unfortunately the ECGs are of low resolution, but they are good enough.


A middle aged woman presented with weakness and dyspnea.   This was her presenting ECG:
What is the differential diagnosis?  What would you do?

There is a sine wave, which is seen with severe hyperkalemia.  It is sometimes called "Ventricular flutter," and is also reported with Class I antidysrhythmics, which are sodium channel blocking agents.

There are pacer spikes.  I don't know if this was a pacemaker provided in the ED, or if the patient has an implanted pacer.  The pacer seems to initiate each beat and the patient may indeed be pacer dependent at this moment.

Tricyclic antidepressants (TCAs) also block sodium channels, widening the QRS, but I have never heard of them causing a sine wave.  This one from Life in the Fast Lane is the closest I have seen.

Treatment of such a patient would include Calcium to treat hyperkalemia, either (preferably) as calcium gluconate, or, if you are certain you have a very good IV, Calcium Chloride (CaCl) (which can sclerose veins).

Remember that to give the equivalent calcium load as 1 g of CaCl, one must give 3 g of Ca Gluconate.  If a patient has life threatening dysrhythmias from hyperK, I know of no upper limit to the dose of calcium.  See this case of VT from hyperK in which I gave 15 grams (doses, "amps") of Calcium gluconate before the patient stabilized.

For this patient, I would give Calcium at least until the serum K returned or further history made the diagnosis clear or the patient stabilized.   I would give Bicarbonate as a treatment for possible Na channel blockers, with the added benefit that it helps hyperK as well.

Clinical Course

This patient later admitted to taking too much of her Flecainide, which is a Vaughn Williams class Ic antidysrhythmic and thus a sodium channel blocker and thus prolongs the QRS.

3 hours later, this was recorded: I don't know what therapy was given, if any. 
The QRS is less sinusoidal and actually has a QRS and a T-wave, and both are very wide.  We can see that complexes only occur when there is a pacer spike, so the patient appears to be pacer dependent.  There are pauses of almost 2 seconds where the pacer does not capture. 

There is also a very long QT, partly because of the long QRS, but also because repolarization (the JT interval)  appears prolonged.   Although at therapeutic doses, flecainide is a Na channel blocker, at toxic doses, it may also block potassium channels, inhibiting repolarization.

With others, my brilliant colleague at Hennepin, Jon B. Cole, MD, Medical Director of the Hennepin-based Minnesota Poison Control System, wrote this great case report on use of intravenous fat emulsion (IFE) in Flecainide overdose:  http://www.ncbi.nlm.nih.gov/pubmed/22882363

Flecainide has high lipid solubility and a large Volume of Distribution (4.8 L/kg) due to protein binding and lipid solubility, making it a great candidate for therapy with intravenous fat emulsion.  However, there are significant uncertainties about this therapy, particularly for ingested (as opposed to parenteral) route of toxicity: the IFE may increase absorption of toxin from the gut.

As for dosing of IFE, the American College of Medical Toxicology (ACMT) currently recommends administering 1.5 mL/kg of 20% IFE as an intravenous bolus over 2–3 minutes followed by an infusion of 0.25 mL/kg/min for 60 minutes.  The bolus may be repeated if cardiac arrest ensues, and the infusion can be increased if the patient demonstrates clinical deterioration.

Thus, it should only be given if the patient is in refractory shock and does not have enough time to be placed on Extracorporeal life support (this is a case of flecainide toxicity treated with ECLS), the most preferable treatment for cardiotoxic drugs.


Very large doses of IV Bicarb, and 2-4 g IV Magnesium (as a nonspecific therapy for long QT), and IFE only if the patient is in refractory shock and cannot be put on extracorporeal circulation.   Transcutaneous or transvenous pacing may be critical as well.  Get the patient on extracorporeal life support as quickly as possible in cases that are likely to be refractory to medical therapy.

For more on intravenous lipid therapy for overdose, visit: www.lipidrescue.org, and this article from Critical Care (full text)

Here is an older (full text) case report of flecainide toxicity.

Defibrillazione e Cardioversione … Shock them ALL !!

  Mi è , ahimè, spesso capitato di notare una grande confusione nell’uso di termini come cardioversione o defibrillazione, per questo ho deciso che un amante della cardio aritmologia come me non poteva esimersi dallo scrivere una “pillola” su questo argomento. Sappiamo che la terapia elettrica è rivolta alla correzione di aritmie ipercinetiche che mettono […]

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