Archive for category TheCentralLine.org

Going to the Scientific Assembly?

Hey everyone! Any The Central Line readers or EM bloggers going to ACEP’s Scientific Assembly 2010? Would love to setup a meetup. Let me know.

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If You Leave

“Admission Denial”

Use in Emergency

Not really words that as an E.D. doc we used to have to think about.   Of course, these words are taking on a whole new meaning for us when we try to readmit that CHF’er who decided they really needed a smoke to go home to “take care of business,”  and we then get push-back from the admitting service or Utilization Review nurse.

It’s not our fault the patient decided that they didn’t like the food. Or that they felt they would get more frequent narcotic administration by absconding from the hospital ward and coming down to the E.D.   I get that patients become bored on the floor and feel like no one is paying attention to them when rounds are just once a day.  I understand that patients sometimes feel like “the doctor wasn’t doing anything anyways just sending me off for a bunch of tests.”  I’m sorry if they left last time;  however, their lung cancer, GI bleed, cardiac disease, end-stage renal disease is a reality, and they really do need to be in the hospital.

Somehow, though, I don’t quite get the patient who was stabbed in the shoulder, had a tension pneumothorax we needle decompressed and who we then admitted with a chest tube, who didn’t want to “wait around the hospital” and so absconded with their chest tube in place and carrying their Pleuravac. To their credit, they did show up back in the E.D. two days later saying that’s when he was originally told he was going to have his chest tube removed and was back to have it taken out.

I also had another patient who developed chest pain and walked to their closest fire department where they proceeded to collapse on the steps. The firemen performed CPR and defibrillated the patient getting back a pulse when EMS arrived. The STEMI was evident on the pre-arrival EKG, and we got the patient to the cath lab within 30 minutes. He, of course, absconded just after his angioplasty because, “he’d been on his way to do something, and couldn’t be sitting around the hospital doing nothing.” He shows up from time to time with anginal pains. Probably because a proper discharge would have included medications which he didn’t get that would have helped with those pesky clogged arteries.

Don’t even get me started on why he hasn’t filled his scripts yet….

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Fingerdance

Let Your Fingers Do the Talking

One of the things that I am going to miss most about being in residency will be conversations like this with my fellow off-service residents:

Mel EM3 in ED: 59M MVC w ICH need consult
Me on Neurosurgery: k b down soon

(20 minutes later…)

Me on Neurosurgery: Plan crani w ventric admit TICU
Mel EM3 in ED: k

Me on Neurosurgery to BB EM2 in TICU: crani ventric 2u s/p MVC
BB EM2 in TICU: k drugs?
Me on Neurosurgery: dil loaded ED by Mel
BB EM2 in TICU: plts?
Me on Neurosurgery: ask Mel in ED
BB EM2 in TICU: k

(Ten minutes later…)

Mel EM3 in ED to both: plts in, bed in
Me and BB to Mel: tnx
Mel EM3 in ED to both: NP 🙂

(One hour later…)
Me on Neurosurgery to BB: crani ventric done C U soon
BB EM2 in TICU: k
Me on Neurosurgery to Mel: big clot, TICU bound
Mel EM3 in ED: nice
Me on Neurosurgery: yep
Mel EM3 in ED: 1 more, SDH 78F s/p fall
Me on Neurosurgery: :p
Mel EM3 in ED: 😀

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Why bother blogging…it’s all about Advocacy (maybe)…

Let’s face it.  I’m an old dude.  I have only been practicing emergency medicine for 16 years but I have 5 years of post graduate training and went to medical school late in life.  Sooo…when it comes to this” techie” stuff I am in my infancy.  My 12 year-old and certainly 20-year old have me beat.  However, as painful as this may be, I decided to “step-up to bat” when I received a note from ACEP asking if I might be interested in blogging.

Don’t get me wrong, I have a few computers and they are not like my first, a Tandy, from Radio Shack that cost me more than three computers in today’s world and it worked on “floppy disks, but now I am really dating myself.  Look, everyone needs to try new technology. I remember my first hand held calculator that I received for college – it weighed about one pound, cost about $100 and could add, subtract, and do square roots!

Now I even have a Blackberry so perhaps I’m not that much of a novice with technical gadgets but I refuse to switch my carrier to AT&T for an i-Phone (although it does look like fun).   And, I even have Twitter, but use it anonymously, since I really don’t think people who don’t know me are that interested in what I’m doing every minute of my life.

As a faculty member in an emergency medicine residency, I was convinced to actually join Facebook.  Perhaps, it was done out of pseudo-peer pressure, but it has added to the camaraderie in the Emergency Department and has reduced stress levels amongst the staff. 

Well enough said about the technical aspects of blogging other than the time commitment to blog.  As a start, I will try and commit to a weekly entry since I have to still work my shifts, teach, take care of administrative issues, and of course be a “real person” outside the ED.  It does scare me looking at all the gizmo’s on this website that the reader doesn’t see like icons for You Tube, insert points for cameras, video, google, Spike….Perhaps I’m out of my league but time will tell!

Oh yeah…one more thing…why was I asked to blog anyway?  Since I have been involved in federal and state governmental affairs with both ACEP and my state chapter, it was suggested that physicians may want to hear a member’s perspective on advocacy.  I will be the first to acknowledge that I am no expert; there are far smarter people out there than me, but hopefully my opinions and observations may motivate others to become more involved in this process.

For now,  please forgive me as I get oriented to the site and all the bells and whistles on this side of the keyboard…and thank God for spellchecker…Wow and I kept it under 500 words…awesome.

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Back to the Future

Skills Lab

I think the first and most lasting memory we all have of medical school is cadaver lab.  That is where we met our first patient and started to learn about disease processes.  It’s where a lot of us experienced death up close for the first time and began our lifelong pursuit of staving it off for as long as possible.  We shared the experience with our classmates – bonding us together as future physicians.  So many friendships (and a few romances) were made over that cadaver.

I remember the nervousness as we decided who would make the first cut.  We started our dissection on the upper extremities, and that first incision to expose the flexor muscles of the arm seemed so impossible.  Who were we to cut into another person?  Shaking scalpel aside, we made our way through.

Today I was faculty at my final cadaver lab of my residency teaching the junior residents advanced procedures such as venous cutdowns and thoracotomies.  There was no hesitation in their hands as we identified landmarks and dissected out veins.  Everyone reached for the scalpel in anticipation of making the thoractomy incision.  Eager hands reached in to find and cross-clamp the aorta.  No nervousness here.  Everyone was eager to cut and learn.

As I count down the final several weeks of my residency and look to my future as an Emergency Medicine attending, I find myself thinking back more and more on my training.  Days like today take me back to where I started;  scared, unsure, wondering if I would be able to pick up that scalpel.  Now I can see where those first tentative days have led me to.  And, I thank all of those patients who gave of themselves along the way so that I could continue the promise I made to that first patient so many years ago…  “Rage, rage against the dying of the light…”

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Apple of my eye

You have to understand- I have been a conscientious objector staging my own quiet campaign against Steve Jobs because when I was in medical school the Macintosh program, which everyone SWORE was compatible with my PowerPoint presentation over which I had labored to produce a riveting lecture for the Neurosurgery in-service on Robotics in Medicine, ate my presentation.  Grrrrrr.  I would have cheerfully strangled Mr. Jobs with a mouse cord.  Then Pixar came along with some of my favorite movies of all time, and my heart began to soften.  Macs became cuter and sexier, though they remained expensive and though I cast an occasional appreciative glance at the curves and bright colors, I remained steadfastly a PC Person.  I loved the modular quality of my PCs and usually did my own maintenance (I am still the Tech Support in our house).  Apple had iTunes, a proprietary interface that grated against my do-it-yourselfedness.  Then came the iPown- er- iPhone.  Its meteoric rise caught my attention.  Sleek, smooth, and it had all that screen real estate!  Tragically, though, it was only available on AT&T.  I didn’t want to change to a new carrier, and hacking the iPhone to use on T-Mobile seemed more trouble than it was worth.  I made due with other phones that I liked well enough, and I was happy.  Then a Sexy Beast arrived on the scene.

The name was terrible- iPad sounded like a feminine hygiene product, and it was nothing more than a glorified iTouch.  Or so I thought.  I researched and read one article after another, though took each with a healthy dollop of sodium since the reviewers were usually dazzled by shiny objects of every kind.  I heard murmurings that it would revolutionize the notebook, but I did not believe.  So one morning after a particularly rough night shift, I decided to see what all of the fuss was about.  I hadn’t gotten a decent gadget in a long time.

It was beautiful.  Smooth.  Clean.  The screen was bright, crisp, and the whole thing felt right in the hands.  Not too heavy, not too light.  Whoa.

Do you remember when the Grinch from the cartoon realized the true meaning of Christmas and his heart grew ten sizes to break open the screen that showed the shriveled thing?  The WANT did that in my brain when the sales guy showed me more than I realized was possible.  It wouldn’t replace my laptop, but it would become my constant companion.  I am not ashamed to reveal that I sleep with it.

So for those who are contemplating joining the iCult of iPad, here is a rundown of some of my current favorite apps, in no particular order:

1)    Medscape – Free- just like the iPhone version, only bigger screen. Lists drugs, interactions, diseases, and procedures.

2)    ePocrates- Free- same as every other ePocrates.  Useful drug information.

3)    MedCalc- Free- Medical calculator.  Just like it sounds.

4)    Medical Spanish- Batoul Apps- $4.99.  Very good medical Spanish app.  It talks!

5)    PubMed on Tap- Free- Easy access to PubMed.

6)    ECG Book- Free- ECG tutorial

7)    Facebook- Free- rapid access to FB, but no live chat available on the free app (there is a paid app that will do that)

8)    Pandora- Free streaming internet radio.

9)    Netflix- Free app with subscription to the service, and movies that are marked “Watch Now” can be watched on the iPad with internet connection.

10) Beat the Traffic- Free, and indispensible in Atlanta, where we have actually had a live zebra running on the interstate.  I am not making that up.  Also helpful for avoiding the bison hazards.

11) iSpy- Free webcam app for those of us with voyeuristic tendencies.  Nothing too racy here, but beautiful views from webcams of Red Square, Lyon, Tokyo, etc.

12) Various news outlets, all free, including WSJ, AP, USA Today, Newsy, NewsPro (Reuters), Bloomberg, BBC News, etc.

13) StarWalk for iPad – $4.99- My favorite astronomy program.  Hold overhead and it will switch to a live view of the skies.

14) iBooks and Free Books- both free, but Free Books is ALL free, and iBooks is a free reader for books that you purchase.

15) The Elements- $13.99- Totally worth it for the song alone, but brings the periodic table to life in an eye-popping display.  This above all others shows the potential of textbooks on the iPad.

16) Pocket Pond- Free- Koi pond.  Weird, but cool.

There are hundreds more, and I am sure you will find your own personal favorites (let me know amattke@aol.com).  None of these programs include movies (available for rent or own, for a fee, of course) or Podcasts, which have become my new guilty pleasure.  My current favorite is Skeptoid, a skeptical look at pop culture.  ACEP, EM:Rap, and Annals of Emergency Medicine have podcasts, as do many of the specialist societies.  QuackCast deals with medical matters in a gratifyingly snarky fashion.  There are many choices, and your mileage may vary.

These are but a few of my favorite things.  iPad does all the usual email, pictures, web browsing, and contacts, and it does them beautifully.  It doesn’t do Flash video, so some web pages won’t look right.  Another of my favorite things is that my calendar automatically pushes with a subscription to Mobile Me.  I can change my schedule on the iPad and it updates my online “cloud”, which then automatically updates my PCs.  Yes, I still have them.  Still a PC person at heart, I still have room for other loves.  And you can have my iPad when you pry it out of my sleep-deprived hands.

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Something to Remember

Grave Reflection We’ve all had that hysterical patient.  The one that comes in during a busy shift.  Grabbing at their head, their chest, their abdomen.  Yelling out that they are in pain.

You know the one.  They makes the nurses’ eyes roll.  They add to an already chaotic scene.  Other patients stop to watch as the gurney rolls by.

You debate how long you’re going to wait to go into the room when the triage nurse hands you the chart and tells you the patient is so agitated that they can’t give her a history.  The EMS crew tells you the call came out as a chest pain, a headache, an abdominal pain.

This is the patient where you go in the room and try to patiently get a history.  You count under your breath as the patient continues to cry and “carry on.”  Finally, frustrated you tell the patient you can’t give them anything until they talk to you and tell you what’s going on.  Even then you might not get some useful information other than their presenting complaint.

You walk out of the room.  The nurse asks, “So what are we going to do with this one?”  You shake your head in exasperation.  “I don’t know.  Let’s start with…”

You jot a quick note.  Go to tend to the other demands of the department.  A while later the EKG or chest x-ray or flat plate or lab result comes back, and you think, “Oh crap!”  You rush back to the room.  Suddenly that crying, wailing patient is the STEMI, the widened mediastinum, the free air in the abdomen.

You look at your watch.  How much time has passed?  What needs to be done?  You start to mobilize your team.  You get the nurse to run extra labs.  You order the CAT scan.  You call your consultants.

You go back in that room with a different view on the patient and start to explain what is going on, try to reassure them, ask them what you can do for them.  You get consents, place lines, make phone calls to families.

The patient is rushed off to the Cath lab, the OR, the ICU.  Then you wait.  You’re seeing your other patients in the E.D. but your mind is on that patient.  What did you miss?  What could you have done sooner?

You get some information.  The patient had a 100% lesion in the LAD, a ruptured AAA, necrotic bowel.  They’re going to Tele, the ICU, or they died on the table in surgery.

You stop and think.  Was I professional?  Did I make them comfortable?  Was I even nice?

Then the next patient comes in the door yelling and screaming that the only thing that’s going to help their pain is “something that starts with a D.. dill… doll…”  You take the chart, go in the room, and start again.

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Evidence-Based Medicine Humor

via Cowbirds in Love.

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SAEM Phoenix Was A Success!

Just returned from SAEM Phoenix — what a great conference! It was especially good for like-minded EM computer nerds. There was tweeting, there was wine and cheese, and It Was Good. Slowly but surely, I think EM physicians will catch on to tweeting, especially at conferences, and especially when there’s free Wifi available. Celebrity sightings included:

  • Nick Genes, SAEM Social Media Chair, Mt. Sinai EM attending and blogger at Blogborygmi;
  • Michelle Lin from UCSF-SFGH and blogger at Academic Life in Emergency Medicine (and with a poster about the blog, too);
  • Rob Cooney, aka @emeducation on Twitter, from Conemaugh Emergency Medicine Residency. I met Rob for the first time, and he’s really doing great stuff, sending out a daily question via Twitter and his residents respond with their answer. It’s a great, fast learning tool that I’ve already started using. He also had a poster about it.
  • Finally, I bumped into Steve Smith from Dr. Smith’s ECG Blog! Steve has an insanely huge archive of EKGs and talks through both his interpretation of them as well as some of the more subtle findings, along with the Cardiology literature that supports it.

Looking forward to hopefully meeting more EM folks in the future!

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How I E-Learn E-M

via flickr's 8bitjoystick

Yes, dorks, I’m back, and with a “Now, More Nerdy Than Ever!” post.

So I’ve realized recently that a lot of people don’t know about all the ways you can learn a ton of emergency medicine online, for free. I really enjoy learning this way, partially because there’s so many different ways to learn online that it keeps it from getting too boring, and keeps you keeping on. We’ll start with the quickest bites of knowledge, via email.

The University of Maryland Emergency Medicine Residency puts out little pearls every day, but did you know you can get them sent to you via email? Sign-up here, and you’ll  get a little bit of knowledge every day in your inbox. (I can’t count the number of times I read one of these and within a week I’m searching my inbox to remember what exactly it said. Always pertinent and always good.)

Next up: the blogs. I’ve previously listed my favorites, but I’m going to highlight the most high-yield educational ones that I love:

  • Top of that list would be Life in the Fast Lane, which literally posts so much content I can’t keep up. Take the Antidote Challenge, for example, which lists a ton of poisons and you have to go through and remember all the antidotes. High-yield, fast, great learning. I don’t know how they post so much.
  • I really like the Emergency Medicine Forum. The poster summarizes a recent case she had, what the pitfalls and critical actions of the case were in her opinion, how she managed the case, with some references at the end.
  • My Emergency Medicine Blog is kind of like the UMEM Pearls. The author takes something he learned from his shift and posts it to the blog with a reference. “Name the 4 indications for non-medical management of a Stanford B dissection,” for example.
  • I can’t leave out my friend Michelle Lin’s Paucis Verbis cards. An index card summarizing what she thinks she needs to know about any number of problems in Emergency Medicine. You can’t get more high-yield.

How do I read all my blogs, by the way? I use Google Reader. It allows you to subscribe to RSS feeds of blogs (and journals and newspapers, and anything else that offers an RSS feed) so you can read all the content in one place. (An RSS feed is a way that sites can share their content with you without you having to visit their website.)

Next up: Podcasts/Videos.

  • EMRAP is probably the most well-known (and is free for EMRA members!). But did you know there’s also a totally free video podcast version at EMRAP.tv? The Mel Herbert Empire also includes some free lectures from the All LA Conference and others.
  • The EMCrit Podcast is both awesome and free, and I’ve learned a ton from it. (And Scott Weingart also posts here. So it must be good, right?) And a secret tip: if you search Google for pages on emcrit (type “site:emcrit.org” and then your search criteria, you’re bound to find something useful. For example, I found the “PAILS” mnemonic for reciprocal changes on this page.
  • I’ve also just recently started listening to Keeping Up in Emergency Medicine, by the Vanderbilt EM gurus. It’s a quick, 30-minute podcast summarizing EM-relevant journal articles where Clay Smith and Jim Fiechtl give criticism and a summary of the findings.
  • Secret tip: You can watch live USC Grand Rounds on Thursday mornings (California time) as well.
  • Hennepin County EM has a bunch of great ultrasound and procedure videos on their YouTube channel.
  • Run out of Hemocult developer? Need to irrigate someone’s eyes and don’t have a Morgan lens? Procedurettes by my absolutely fantastic attending Whit Fisher will save your butt every time.

Finally, Journal Articles. This only kinda-counts, but here’s a bunch of great online resources:

  • EBMedicine. Insanely great, evidence-based diagnostic and management summaries on almost every EM topic by now.
  • I heart The Emergency Medicine Clinics of North America. Shorter than EBMedicine but provide a great overview of many topics, and each issue focuses on a certain theme. You can access them as well if you’re a member of mdconsult.
  • ACEP also provides its Critical Decisions in Emergency Medicine series, which are probably the shortest of all these options, but pretty good as well.

So, you’re asking yourself, how do I keep track of all of this? A private blog, of course. Whenever I read a good article or find something useful that I don’t want to forget, I summarize everything on the private blog and link or upload the PDF of the article I read it in. This way, I can always have access to the information as long as I have an internet connection. If I tried to store it all away in a notebook, it’d either get lost, fall apart, or I’d just forget it at home and be none the wiser.

(And one final tip, you can now save PDFs that you’re viewing with Google’s PDF reader to your Google Docs account.)

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