Clinical Decision Rules in EM - Interactive iBooks

We are looking for participants in an educational survey about two modules we wrote in the interactive iBooks format. The goal of the modules are to assist Emergency Medicine faculty, residents and medical students in better understanding the evaluation and work up of patients presenting with a suspected PE or minor head injury.  The modules integrate primary sources from evidence based medicine, relevant clinical multimedia, interactive review questions and multiple layers of information for different levels of learner.

Interactive iBooks can be viewed on a Mac computer running OS X Mavericks, a new operating system released as a free software update last week, or on the free iBooks app (version 2 and up) on an iPad (mini or generation 2 or above with iOS5 or later). Interactive iBooks cannot be viewed on an iPhone.

The modules can be downloaded directly from this link: http://bit.ly/emrules

To use on your desktop, download the file and open it using iBooks. To use on your iPad, open the link on the iPad, choose Download, then Open in iBooks.

At the conclusion of each module is a link to a brief survey that focuses on the usefulness of these devices for teaching in the healthcare setting.  We are asking that you complete the respective survey by clicking on the link at the end of each module. 

• Survey for PE

• Survey for Head Trauma

Participation in the survey is completely voluntary, you can decline to participate or stop your participation at any time, if you wish to do so.  The study met criteria for exemption for informed consent by the Institutional Review Board, Temple University School of Medicine.  Thank you.  If you have any questions, please contact Dr. Wald at waldda@tuhs.temple.edu or 215-707-5879. 

Advice to new EM interns

The 10 Commandments of EM  are now over 20 years old, but still a must read before intern year. Dr. Rob Cooney did a great review of the original article on Better in EM. The commandments:

1. Secure the ABC’s
2. Consider or give naloxone, glucose, and thiamine
3. Get a pregnancy test
4. Assume the worst
5. Do not send unstable patients to radiology
6. Look for common red flags
7. Trust no one, believe nothing (not even yourself)
8. Learn from your mistakes
9. Do unto others as you would do to your family (and that includes coworkers)
10. When in doubt, always err on the side of the patient

I wanted to add a few bits of advice that have helped me as a resident:

1. Treat Pain. 

While you're debating what labs and imaging are needed to diagnose your patient, it's really easy to forget to treat the symptoms that they came in for in the first place. Do your best to help them feel better.

2. Ask the patient what they think is wrong with them.

On my first week of intern year, an attending told me "Patients will often tell you what they think you want to hear to get them what they think they need. It's your job to figure out what's actually going on."

I've found it tremendously useful to actually ask people what they think the problem is and what their biggest fears are. It has completely changed my management in several cases. Most importantly, it helps me address their specific concerns. The patient complaining of shortness of breath that got discharged yesterday may not actually here with uncontrolled symptoms, he's worried that he has lung cancer and thinks he needs a CT. Addressing those concerns directly makes everyone's life easier.


3. For every test you order, ask yourself why. What are you looking for? How will this effect your management?

Everything you order will cost your patient and/or your hospital money. More importantly, no test is benign. CT's come with radiation exposure and incidentalomas. People generally hate getting stuck with needles. Borderline lab results make dispositions difficult, especially when they are actually irrelevant to the complaint. Don't subject your patient to a more expensive and risky workup unless it's actually going to help them. No one wants to be a VOMIT.

This is a cat. 

4. Learn to put in IVs.

We get really good at ultrasound guided peripheral IVs and central lines, but it's still important to master doing regular old IVs. As long as it's keeping your skills up and not preventing you from seeing enough patients, it's probably not scut work.

5. See the patients that scare you.

When you read a triage note and your first impulse is to avoid the patient, you should probably see them. Confront your fears and your weaknesses and you'll be a better doctor.

That said, if you're concerned about your personal safety, problem solve with your team. The ED can easily devolve into unpredictable chaos, so we all need to be vigilant about keeping our workplace safe.

Free Medical Apps for Residents

Our hospital recently started a program where all residents are issued iPhones. Not only was this a great way to improve clinical communication, but it also allows us the opportunity to use mobile apps.

The phones automatically came loaded with the Calculate (medical calculator) by QxMD and Micromedex for drug reference. I was glad to recommend seven other free apps that I thought would be useful. These are now also approved for our residents to download to their work phones. Each link below takes you to the iTunes listing for each app.

• Read: Personalized Medical Journal
• New England Journal of Medicine
• One Minute Ultrasound
• SonoAccess
• Radiology 2.0: One Night in the ED
• 3D Brain
• Ahrq ePSS

As a staff writer for iMedical Apps, I will continue to keep an eye out for other great mobile medical apps for residents.

Life in the Fast Lane and Academic Life in EM are two other great sources of EM focused medical app reviews.

A Critical Eye on Mobile Technology in Medicine

Right after starting this blog, I became a staff writer at iMedicalApps, an online publication on mobile medical technology. I've really enjoyed working with them and reviewing medical apps on the iOS platform, though this means that my time for independent blogging on this site has been limited.

So why do I think it's worthwhile to review apps? As medical education embraces new technology, I think it's essential for us to look at new resources like mobile apps with the same critical eye that we use for evaluating traditional resources like medical textbooks and peer reviewed publications. At the same time, this is a fantastic opportunity to experiment with new ways to use technology in teaching, independent learning, and clinical practice.

Cardiac Catheterization is a patient education app

Iltifat Husain, the editor in chief at iMedicalApps, is also an Emergency Medicine resident. I respect the way he's created the site to be an independent, reputable resource for other health care providers. The focus is on finding how mobile technology can be used wisely and effectively, not on what's trendy. We're encouraged to honestly review the apps and to be clear about those that we would and would not recommend. Iltifat's recent review of AliveCor is a great example of how physicians should investigate new technology - not just focusing on if and how it works, but also if and how it can actually be useful.

Interactive iBooks are a new technology that I think have great potential for influencing medical education. I enjoyed reviewing Introduction to Bedside Ultrasound, a fantastic resource on the iBook platform.

I also wrote a commentary piece on the limitations of iBooks in their current form, and ideas for problem solving how they could be more accessible and useful to medical educators.

Can a medical apps make us better doctors? CPR Game is a great example of using technology to explore new ways of learning. This serious game simulates a cardiac arrest scenario and teaches resuscitation skills by encouraging players to identify and preform critical actions in a timely manner to save their patient. I found that playing this game helped me remember my resuscitation ABCs and keep a level head when working on medical codes. I look forward to seeing more fun, interactive teaching tools like this in medical education.

On the other hand, I reviewed some apps that I wouldn't recommend to other physicians. Coags Uncomplicated seemed like a great free educational app at first glance, but in the end turned out to have a hidden agenda - it was created by a drug company to sell more drugs. I called out Emergency Medicine iQ, a board review app, for having inaccurate references and incorrect explanations.  I also question the role of some apps in clinical practice - is it safe to use an app with an automated ECG algorithm? I don't think so.

All in all, reviewing apps has been a fun experience that has helped me find new med-ed resources, and learn about the pearls and pitfalls for using medical apps as a physicians.

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:

LITFL: TranMan goes Viral; Critical Care Drug Manual: Tranexamic Acid

The NNT: Number Needed to Treat: TXA in Severe Trauma (1:67)

Resus.Me: Tranexamic Acid Saves Lives in Trauma; How about pre-hospital tranexamic acid?

St. Emlyns: Tranexamic Acid for Everyone?

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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.

Midazolam

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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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!