Introduction to CasemasterIQ: Deliberate practice in Emergency Medicine

This is an introduction to software I developed that enables deliberate practice in emergency medicine. Studies show that deliberate practice leads to mastery.  Don’t worry though, you won’t need to spend 10,000 hours on these cases! I think that by using CasemasterIQ you will be able to perform deliberate practice, master the correct approach to clinical challenges, and greatly improve your cognitive skill set! Check it out and email me for any questions you might have!

Mindfulness in medicine: Physician heal thyself

Physicians are among the most unhappy, stressed out professionals. In fact, there is tremendous job dissatisfaction throughout the house of medicine. In this first in a series animated video cast, I describe how physicians can explore mindfulness to recognize when stressful situations are bringing out their worst traits and why that happens. I discuss the value of treating these difficult moments with kindness, curiosity, and acceptance. I believe we can use mindfulness to explore how various fears very personal to our own situation function as the subconscious engine that drives behaviors that are destructive, disruptive, and depressing. Physicians can return to a positive state of mind and the excitement of those first moments of fulfillment they felt when they started their journey in medicine if they adopt mindfulness techniques.

 

Journal Club Podcast for April 20

Abscesses: Lancing the myths! This podcast and the journal club answer the following questions:
Irrigate and abscess: yes or no?
Pack an abscess: yes or no?
Antibiotics for an abscess: yes or no?
Ultrasound an abscess: yes or no?
Inject lido or lido/tetra patch: which is better?
With the usual tangential flight of ideas that accompanies these ‘casts – such as what was buffered lidocaine and why don’t we bother using it anymore?

Here are the articles – at the end is the study by Jerry Hoffman (okay so it was an abstract) that showed that buffered lidocaine was not worth much to the patient.

Chinnock, Brian et al. Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success Annals of Emergency Medicine , Volume 67 , Issue 3 , 379 – 383

O’Malley et al Routine Packing of Simple Cutaneous Abscesses Is Painful and Probably Unnecessary Academic Emergency Medicine 2009; 16:470–473

Talan DA et al. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess N Engl J Med. 2016 Mar 3;374(9):823-832.
Alsaawi et al. Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature. Eur J Emerg Med 2015

Bourne et al Injectable lidocaine provides similar analgesia compared to transdermal lidocaine/tetracaine patch for the incision & drainage of skin abscesses: A randomized, controlled trial J Emerg Med. 2014 Sep;47(3):367-71

Tornay et al Heated versus buffered lidocaine and the pain on local injection: A comparative study Annals of Emergency Medicine 1994 , Vol. 23, Issue 3, p629
Small study that showed most patients would not pay $2 for buffered lidocaine.  “Heating a solution of lidocaine with epinephrine reduces the pain of local injection, but buffering with bicarbonate is more effective in this regard. The value of this difference to the patient may be minimal”

Be a stud med student in 3 mins! Guaranteed!

Tips on EM presentations skills

Michael Pasirstein MD

Why

Students have already had a few years of being taught by other departments how to do an oral presentation, but it may not be applicable to EM.

Majority of the student and resident educational interactions with attending physicians in EM occur during oral presentation.

Student evaluation is directly linked to how well the student presents.

About the article

The authors are using their success to assist learners present all pertinent information in under 4 minutes

History of the Oral presentation

Earliest mention of the oral presentation is from the dean of the New Orleans Medical School, Erasmus Fenner, in 1846, though it seems intuitive that doctors and learners have been communicating with oral presentations much longer than about 200 years.

In 2003, the SNAPPS format of presentations was developed at Case Western Reserve University School of Medicine. This format was designed for outpatient oral presentations. The SNAPPS method focuses on

  • brief patient summaries
  • Narrowing DDx of 2-3 etiologies
  • Analyzing information to determine the most likely cause of chief complaint
  • Probing the attending for knowledge
  • Planning pt management
  • Selecting an issue for self-directed learning

Students noted that:

Effective presenters alter the way they present but had difficulty describing how, making it difficult for novices to mimic

 

EM

The origins of the oral presentation and the recent studies noted previously are not EM specific

In EM we:

  • Assume every patient has an emergent condition
  • Have multiple undifferentiated patients at once
  • Prioritize patients
  • Have incomplete patient data

 

EM Oral Presentations – How are we different?

  • CC
  • HPI
  • Meds/allergies
  • PE
  • Summary statement
  • Assessment and plan

What is minimized are

  • PMHx,
  • PSHx
  • Soc Hx
  • FmHx
  • ROS

Essentially, the HPI should include all the pertinent information from those areas that are minimized.

Earlier learners will still have items that are positive in the ROS, as they may not be aware of what is pertinent and what is not.

To further improve speed, the student should include only pertinent positives and negatives on physical exam.

The 3 Minute Emergency Medicine Medical Student Presentation: A variation on a theme.

the-3-minute-emergency-medicine-medical-student-presentation-a-variation-on-a-theme-pdf-

K2 Krash

K2 Krash – what to do?

What is the K2 Krash – it’s the phenomenon of hypotension and bradycardia after a synthetic cannabinoid overdose. Typically an overdose with hypotension and bradycardia is a life-threatening phenomenon, for example calcium channel blockers and beta blockers. K2 crash seems to be less life-threatening and responds well to fluid resuscitation unlike other poisonings with the same cardiovascular effect.

I suggest you follow Leon Gussow’s tip on managing hypotension in overdoses – scan the IVC and fill up the tank until the respiratory collapse of the IVC is replaced with a plump IVC and then add pressors if needed or wait out the metabolism of the synthetic cannabinoid. Typically the clinical course of hypotension is less than six hours.

http://journals.lww.com/em-news/Fulltext/2014/07000/Toxicology_Rounds__An_Idea_Whose_Time_Has_Come__.10.aspx

 

We do know that the K2 Krash is the result of stimulus of the CB1 receptor. We also know that endogenous cannabinoids are released by platelets and macrophages during sepsis. Whether they in fact have a protective effect remains to be seen, but they appear to result in vasodilation of the brain and coronary vasculature. Perhaps that’s why K2 Krash appears to be a relatively benign event once it resolves.

Here’s a great article on cannabinoid induced hypotension.

Cannabinoid-Induced Hypotension and Bradycardia J Pharmacol Exp Ther-1997-Lake-1030-7

A nice case series on synthetic cannabinoid overdoses – about half of which demonstrated bradycardia and hypotension. Synthetic Cannabinoid Abuse in Adolescents: A Case Series

Also a discussion on how synthetic cannabinoids play a role in sepsis. Platelet- and macrophage-derived endogenous cannabinoids are involved in endotoxin-induced hypotension

Enjoy and let me know what you think!

 

 

TM-SMX and Abscess I&D and ECMO in the poisoned patient

In this podcast I review “Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess” Talan et al NEJM 2016;374:823-32 and see what the clinical advantage to adding TM-SMX to simple I&D. Then we take a quick turn to some Tox and look at “Extracorporeal membrane oxygenation in the treatment of poisoned patients” deLange et al in Clinical Toxicology 2013;51:385-393.

ECMO in poisoned patient

4XTRIM SULFA BID and MRSA Abscess

Okay so – so it’s a little weird to have those two – but hey that’s what I am reading…

Enjoy and let me know what you think