Sunday, October 7, 2012

Comics, Claymation, and Hemorrhagic Shock: TXA Redux

Ian Roberts really, really wants you to give Tranexamic Acid (TXA) to trauma patients at risk for significant hemorrhage. Ideally, you'll read his recent paper in the BMJ, but if that doesn't grab your attention, he wrote a comic (pdf link) and a claymation video about it, too. There's even a cheesy but endearingly eager song about the drug. It's a laudable effort to get physicians interested in new research on a cheap, generic drug without any big pharma money behind it.

Dr. Roberts is an investigator on the CRASH-2 Trial (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage), which enrolled over 20,000 patients worldwide in a double-blinded randomized trial on the effects of tranexamic acid in acute hemorrhagic shock. They showed that if given in the first three hours of a traumatic hemorrhage, this inexpensive and low risk drug can reduce mortality by 30%.

After the initial CRASH-2 results were published in 2010, few trauma patients were receiving the drug despite its inclusion on the WHO Essential Medicines List.  That dilemma inspired Roberts to create the claymation video above. (Lancet: CRASH-2 goes viral).

Last month, a new CRASH-2 paper on subgroup analysis by risk of mortality was published in the BMJ. Then the London School of Hygiene & Tropical Medicine (LSHTM) launched the comic as the next step in their a campaign to publicize the trial results in hopes that more physicians will use TXA. They also published a series a videos about the trial on the LSHTM YouTube page. The NYTimes picked up the story. The comic is a quick read with salient learning points and an amusing amount of ED drama.

“We have to do something about that bleeding.  Get me an IV line and one gram of tranexamic acid now!"

The streamlined, international research methodology of the CRASH-2 trial is impressive, but their publicity methods are equally inspiring. The latest BMJ study is a free, open access publication available on PubMed Central. The CRASH-2 home page offers extensive resources for clinicians about their research in 6 different languages. The multimedia resources convey both clinically relevant data and the enthusiasm of the investigators. This is an exemplary model of how to translate clinical research into clinical practice worldwide. I hope more investigators follow their lead. This is what FOAMed (Free Open Access Medical Education) is all about!

Research review:

Roberts I, Perel P, Prieto-Merino D, Shakur H, Coats T, Hunt BJ, et al.
Effect of tranexamic acid on mortality in patients with traumatic bleeding: prespecified analysis of data from randomised controlled trial. 
BMJ 2012;345:e5839 PMID: 22968527 PMCID: PMC3439642 

What is already known on this topic

  • Tranexamic acid given to patients with traumatic bleeding within three hours of injury significantly reduces mortality with no apparent increase in adverse thrombotic events
What this study adds

  • The beneficial effect of tranexamic acid on all cause mortality or deaths from bleeding is not affected by baseline risk of death
  • There were fewer thrombotic events with tranexamic acid with no evidence of heterogeneity by baseline risk
  • Use of tranexamic acid should not be limited to high risk patients
Additional resources:

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Wednesday, September 26, 2012

One week in FOAM

Many residents and faculty have approached me with questions about using Free Open Access Meducation (FOAM) and social media, and often report feeling confused and overwhelmed by the amount of resources out there. On a practical level, they wonder - what does learning from FOAM actually mean?

This post started off as an email to other residents in my program in order to give concrete examples of how I use online resources and our residency's social media account as a part of my education.

For starters, I think the role of online resources - Twitter, podcasts, and blogs - is largely to expand upon traditional textbook learning and published literature to enable dialogue and critical thinking about how we use that information. As someone who finds textbook learning alone challenging, I use online resources to increased the “stickiness of what I’ve learned so that I can remember it, understand it, and apply it in my practice.

Here’s a contextual example of how I used the residency Twitter account recently. At Journal Club, we talked about an article reviewing Haloperidol vs. Midazolam vs. Lorazepam for chemical restraint in acutely agitated patients. I tweeted a link to the article and some of the clinical pearls from our discussion. I haven't used much Midazolam for chemical restraint, and was intrigued by the quick on / quick off argument. Michelle Lin from UCSF responded with her own practice. A Community EM doc who likes to use Lorazepam and Haloperidol in the same syringe wondered about mixing Midazolam and Haloperidol and reached out to an EM pharmacologist for an answer - maybe you can, maybe not.

I went home and read Rosen’s (which I happen to read online/on my phone because the book is too big to carry around) on acutely psychotic patients, which had a helpful review of the diagnostic criteria for schizophrenia, tips on getting a good psychosis related H&P, and an outline of organic illnesses and medications that can also cause acute psychosis. It covered the Haloperidol and Droperidol FDA warnings briefly, and recommended the common Haloperidol 5-10mg and Lorazepam 1-2mg given IM or IV in the same syringe for chemical restraint. It did not discuss Midazolam specifically.
Bedazolam: a sparkly compound rarely encountered in the wild
Then I posted a link from Joe Lex, one of our attendings after ACEP tweeted the full text of a new trial in Annals comparing midazolam +/- olanzapine or droperidol for chemical restraint. EMRAP did an hour on chemical restraints last month with many different perspectives from EPs around the US and abroad, so I posted a link to that as well. (Sidenote: Apparently, there aren’t very many emergencies in Sweden. Sounds like a tremendously healthy and boring country.)

Result: I did some good critical thinking about chemical restraint, combining what I learned from the textbooks, the evidence based literature, and the practical advice of Emergency Med Faculty from Temple, other academic centers, and docs from the community. The process was easy, practically instantaneous, and immediately rewarding.

I’m going to remember that information and use it. I hope that tweeting those resources helps other residents review that information and think critically about it as well.

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Tuesday, September 25, 2012

Riding the wave.

In this overstimulated modern age, it may seem that there is a plethora of ways to learn medicine and build up your EM Armamentarium. Blogs! Podcasts! Tweets! Videos! Not to mention the massive textbooks still on the shelf. Lately, Free Open Access Medical Education (FOAM for short) has taken off as a new and rapidly growing method of learning, with tweets flying on everything from ultrasounding abscesses to glucose control in the ICU.

That's all well and good, but what's a doc to do with all this stuff? It's challenging to devise a system to ride the wave.

As an Emergency Medicine resident just starting my second year, I'm still developing my own learning system. I recently started a twitter account for my residency program, and am still figuring out the best ways to use it.  

There are some big, unanswered FOAM related questions looming in my mind:

  • How can resident physicians realistically and practically use FOAM resources to augment traditional textbook learning?
  • How can a residency program use social media to catalyze that process?

I don't know the answers, but I aim to have fun trying to figure it out and documenting that process on this blog. 

My specific goals here are to:

  • On a practical level, document my own learning process as an EM resident using new and traditional learning methods, from Rosen's to following #FOAMed posts on Twitter.
  • Reflect on how using social media augments my learning process.
  • Explore the evolving role of technology in medical education.

Hopefully this can serve as a helpful model for other EM learners and spark discussion about EM education. I look forward to your feedback and to having some fun with this project!