About Al'ai Alvarez, MD

Section Editor, ALiEM Medical Student Home Page
Clinical Associate Professor
Director of Well-being
Co-Chair, The Human Potential Team
Department of Emergency Medicine
Stanford University School of Medicine

Trick of the Trade: Managing Epistaxis with Merocel Nasal Packing and an Angiocatheter


There are many ways to manage epistaxis. Once nasal clamping and cauterization fail, the next step is to consider using tranexamic acid (TXA) and performing nasal packing. Inflatable packing devices such as a Rhinorocket are painful to insert and do not conform well to the shape of the naris. The expandable Merocel nasal packing, a compressed, dehydrated sponge, provides a softer, alternative option, although the insertion process can be painful given its initial rigid, edged structure. We propose 2 strategic tricks to optimize your nasal packing technique using the Merocel sponge.

Trick of the Trade: Strategic expansion of the Merocel sponge

The common approach for Merocel packing involves inserting the unexpanded sponge into the nose, tilting the patient’s head back, and dripping in TXA solution to expand the sponge to tamponade the bleeding.

Trick #1: Wet the tip of the Merocel’s sharp edge to allow for a softer cushion to slide the packing more comfortably and deeper into the naris.

Trick #2: Use an angiocatheter to deliver the TXA solution directly onto the mid-portion of the packing. Commonly, the TXA solution is dripped onto the outer end, which may cause an uneven and inadequate expansion at the site where the bleeding may be occurring. Because blood also can react with the packing, it is likely the blood will expand the packing before TXA reaches the center by osmosis. Another benefit of Merocel expansion starting at the center is that it will help anchor the sponge in place. In contrast, TXA administration at the outer tip first may pull the sponge out of the naris a few millimeters.

Equipment

  • 20g or 22g angiocatheter (closed IV catheter system)
  • Tranexamic acid solution
  • A syringe
  • Merocel nasal dressing

Technique

merocel sponge nasal packing trick setup

1. Insert the angiocatheter needle into the Merocel packing about ⅓ the distance from the external end of the packing. Remove the needle, leaving the plastic angiocatheter in place.

merocel tip moisten txa trick

2. Soak the insertion tip of the nasal packing with a drop of TXA to soften it. Or apply a light coat of an antibiotic ointment or petroleum jelly to the insertion tip for lubrication. This will make it easier to advance the packing and also less painful for patients. Advance the Merocel into the affected naris just as you would a nasogastric tube. Some additional tips are in the ALiEM article about nasogastric and nasopharyngeal tube insertion.

3. Once the nasal packing is fully inserted, expand the sponge by administering TXA via the attached angiocatheter. The mid-portion of the sponge should expand first, thus preventing outward slippage of packing. Also TXA more quickly reaches the area of bleeding rather than from a more gradual osmotic effect when dripped in from the external tip.

How I Work Smarter: Al’ai Alvarez MD

One word that best describes how you work?

Compassion

Current mobile device

iPhone 12

Computer

MacBook Pro

What is something you are working on now?

Where do I begin? The pandemic has opened doors for virtual talks and conferences, so I’m just taking it week by week sometimes. I’m also doing a fellowship, the Stanford Byers Center for Biodesign Faculty Fellowship. I’m learning how to apply design thinking to well-being interventions in the ED, and hopefully collaborating with other high-performance teams. I am also co-directing a conference in May 2022 on High-Performance Resuscitation Teams.

How did you come up with this Idea/Project?

re: High-Performance Resuscitation Teams Conference, I have been attending the Mission Critical Teams Institute summits over the past several years. We wanted to create a conference focused on healthcare and high-performance teams. I’ve had the opportunity to center my areas of interests in Medical Education, Process Improvement (Quality and Clinical Operations), Recruitment (Diversity), and Well-being (Inclusion) through human-centered design. A natural area was focusing on team performance and professionalism under stress.

What’s your office workspace setup like?

I’m in the middle of 5 people-office space. I have a plant, some snacks, and a big monitor. I haven’t been there in months. My home office is somewhat similar.

What’s your best time-saving tip in the office or home?

Paper and pen writing of big deadlines in a week. I’ve tried calendaring after learning from Dr. Jennifer Kanapicki, though I have yet to develop the discipline to do this weekly. My coach offered an alternative, which is focusing on 3 big projects a week to focus my energy. This helps me put things in perspective, as opposed to having so many loose ends, and writing it down cognitively frees up memory space for me.

What’s your best time-saving tip regarding email management?

Quick run-through in the morning, and start deleting.

What apps do you use to keep yourself organized?

On Chrome: OneTab for all my tabs. Omnifocus for my to-do stuff. My calendar is a part of my life so my calendar is an extension of my brain. When2meet to find mutual availability for meetings plus My calendar with zoom links.

How do you stay up to date with resources?

Twitter. I know.

What’s your best time-saving tip in the ED?

Eyeball patients immediately so I have a sense of who’s sick and who’s not. Talk to the nurses. They know more about the patient most of the time. For the rest, I follow the mantra, “Quality care takes time,” and I am on the faster end of the dispositions in my group, as I’ve learned to be more comfortable with managing uncertainties.

ED charting: Macros or no macros?

No macros. I also don’t chart as much as I should. I write for the sake of documenting and not for billing. I’m OK with that. We can’t do it all.

Advice

  • What’s the best advice you’ve ever received about work, life, or being efficient?

    #selfcompassion. Can’t do everything perfectly. Show up. Learn to say no. The power of perspectives. In 1 week, 1 month, 1 year, 10 years will this really matter? This grounds me on how I tackle tasks and often the emotions surrounding deadlines.

  • What advice would you give other doctors who want to get started, or who are just starting out?

    Easier said than done, practicing self-compassion has allowed me to really develop a growth mindset. To start, simply doing a daily mindfulness practice of even 5-10 minutes. This trains my mind to slow things down when things become chaotic. This also trains me to be attuned to how my body reacts to stress, and therefore, tending to it whenever I notice these sensations (neck stiffening up, etc).

  • Is there anything else you’d like to add that might be interesting to readers?

    I may be doing a ton of stuff, and in the background, I’m doing a ton more and failing. For me, the more things I’m working on that I’m truly passionate about, the more I get done. I’m OK with failure, and whenever I do (and not if I do), these offer me a great opportunity to learn how to be better (or choose better opportunities). Last and also very important, I find the collaborations bring more meaning to my work.

Read other How I Work Smarter posts, sharing efficiency tips and life advice.

By |2022-01-18T09:55:16-08:00Jan 21, 2022|How I Work Smarter, Medical Education|

Trick of the Trade: Persistent Paracentesis Leakage 2.0

Paracentesis leakage

You’re seeing a patient returning to the ED after a recent diagnostic paracentesis. The patient is complaining of persistent peritoneal fluid leakage. They’ve tried putting pressure with no success. You tried applying a medical adhesive glue and noticed it was unsuccessful, based on the patient’s gown continuing to get wet with ascites fluid. Now what?

Trick of the Trade: Pressure Gauze and Transparent Film Dressing  

The medical adhesive glue trick was proposed in the Trick of the Trade 1.0 version by Dr. Borloz and Dr. Lin in November 2012. 

Materials Needed

MaterialQuantity
Benzoin tincture1
Gauze 2″ x 2″1-2
Transparent Film Dressing (Tegaderm) 2.5″ x 2.75″3-4

Technique

1. Apply benzoin tincture surrounding the area of the leakage.
gauze ball in hand
2. Use a 2″ x 2″ gauze and roll it into a tight round ball. Hold the gauze with firm pressure over the leak (it is easier if you have the patient or an assistant holding it in place while you move on to the next step).
4. Stretch the transparent film dressing before placing it over the center of the gauze
4. Continue to hold firm pressure on the gauze from over thetransparent film dressing. Note that you are not yet touching the dressing against the skin.
5. Stretch outtransparent film dressing and affix to the patient’s skin.
6. Once you apply the initial transparent film dressing, you can apply 2-3 more over the top, in the same fashion, to increase the pressure on and security of the dressing. Patients may be discharged with this dressing in place for 24-48 hours.

Pro Tip

Consider combining both this trick of the trade and the adhesive glue technique. Hat tip to Dr. Christian Rose [Twitter @RoseLikeTheFlwr] for this idea. 

Interested in other Tricks of the Trade posts?

Read the series of Tricks of the Trade posts.

By |2021-10-15T12:48:11-07:00Oct 20, 2021|Gastrointestinal, Tricks of the Trade|

Reading from the Silver Linings Playbook: The ALiEM Connect Project

ALiEM Connect graduation

It feels like yesterday that we were sheltered-in-place, staring at our computers, wondering, “So now what?” 

As COVID-19 paused all in-person educational sessions, the early morning residency conference we used to begrudgingly join quickly became something that we profoundly missed. While we can now be “present” while wearing sweatpants and a button-down shirt, we miss the human connection. Many of us would gladly even suffer through traffic just to be a part of this morning conference tradition.

As educators and innovators, we know what a disruptive force the COVID-19 pandemic has been to the medical community. It has strained our medical and healthcare systems and has irrevocably altered our day-to-day lives. Without a doubt, the pandemic also changed how we delivered educational content to our learners over the past year.

Scholars have written about how likely this pandemic will likely precipitate the much-needed digital transformation of healthcare and health professions education that many of us have expected and hoped for. But while some of these innovations are born out of necessity, they may also inadvertently isolate us from the experiential aspects of education and human interaction that provide meaning to our work. For the ALiEM team, we cherish the opportunity to be part of some of these significant innovative and positive “disruptions,” further aligning our goal of creating an impactful and fulfilling academic life in emergency medicine. 

The Backstory

As a remote team working across continents, the ALiEM team has thrived on digital connection for over a decade. With excellent collaborators and volunteers representing different parts of the world, our daily operations require us to stay connected and work asynchronously to achieve our goals and deliverables. When the lockdowns hit, we leveraged its impact on physical distancing and leaned into connecting with each other even more! They say “chance favors the prepared mind,” and there we were, already on Slack and yearning for the opportunity to harness the power of teamwork using our shared passions, individual creative strengths, and enthusiastic and supportive emojis. There were moments of creating, moments of celebration, and moments of simply being with each other – often through an evening #WifiAndWine.

By the Ides of March 2020, an auspicious time indeed, we knew we were at a turning point. Our friends and work families had been working on the front lines combating the pandemic locally, gathering PPE, and studying the effects of a virus we knew next to nothing about. New information was coming in daily, and the signal-to-noise ratio was low. In some ways, to escape the disruptions going on all around us, we banded together to focus our unique energies toward creating something as novel as the virus itself in the realm of free open-access medical education.

At a time where everyone was feeling alone, we asked ourselves how we could support the joy of learning from and with each other? In truly whirlwind fashion, the first ALiEM Connect conference went from idea to execution in less than 2 weeks, a record-breaking time even for ALiEM. Thank especially to the American Board of Emergency Medicine for sponsoring these events.

We recently made it to the semi-finals at the CORD/ACEP Innovator of the Year competition, where we shared the below video capturing the fun, collaboration, and innovative outcome of our efforts. Oh, and the familiar ratatat of Slack.

Making this a Multiple Win

The secret sauce of the ALiEM team is that we have a diverse group of people, each of whom brings their own perspective and that we are able to share with one another liberally. Dr. Michelle Lin encouraged an environment that is psychologically safe and supportive since the inception of the ALiEM enterprise. It is out of this space that our diverse team was able to successfully bring a massively successful project to fruition amid a global pandemic. What started as a small brainstorming session blossomed into ALiEM Connect – 3 distinct remote conferences featuring nationally-recognized educators and thought leaders enjoyed by residents across the country.

It’s difficult to express as a linear narrative, but looking back, it seems as though our team divided into unique roles without a second thought. Just like a production company, we had the front and back of the house. Those in the front made sure to help get people in the seats to watch; stage managers and coordinators ensured that every part of each of the ALiEM Connect experiences was phenomenally smooth. We had talented individuals who acted as hosts and speakers to ensure that each of these experiences was top-notch and engaging. In the back, Drs. Mary Haas, Yusuf Yilmaz, and Teresa Chan sprung quickly into action to create a program evaluation strategy for our ALiEM Connect program, including a formal institutional review board exemption! All the while, testing and vetting platforms and methods to distribute the material were ongoing. We built upon each technological skill, learned new platforms, and trialed different features. We had barely decided on an open, free, and accessible platform (which was, in fact, no individual platform but an amalgamation of many!) before sending out the invites.

But the fun didn’t stop there! We’re the “academic” life in emergency medicine! How could we not also share our results with the traditional academic community? Within days of finishing our first ALiEM Connect experience, our program evaluation team generated the scaffolding of a manuscript to put together our thoughts and analyze the evaluation data collected. We harnessed the power of metrics from social media platforms (YouTube, Slack, Twitter), website analytics, and end-user experiences. Harnessing all of these analytics and communicating the right message with our academic medicine community was important to inform and help others to replicate similar approaches to their residents. Our team used ready to use metrics which came from YouTube analytics. But we did not stop there as we needed more reports of how the residents and programs interacted during the Connect events in the backchannel, Slack. We developed Python supported software to export and analyze all the messages happening in separate channels. We developed a “Emoji Cloud” to see how the reactions happened, and closely analyzed the messages during the event.

Given the true novelty of the experience, we figured we might as well shoot for the moon, as they say, by submitting our innovation description paper to Academic Medicine. After all, even if they didn’t accept it, we might get some constructive reviews, to say the least. As innovators, we are comfortable with the possibility of failure. We understand the value of the saying, “You miss 100% of the shots you don’t take,” and were prepared to accept “no” as an answer. With that, we took a calculated risk, making use of the same collaborative strategy to craft a manuscript, and clicked submit.

…And we’re glad we took that shot! We are excited to share that what we sent was indeed accepted and express our gratitude for the chance to share our low-cost approach to a large-scale, nationwide residency conference! You may read the Published Ahead-of-Print version of our paper.

Moral of the story…

You might be asking yourself, “What’s the moral of the story here? Of course, with enough academics and experts, yeah, you got a paper published. Cool…” But the papers aren’t the point. In fact, during the COVID-19 pandemic, more papers have been published than ever before – more research is being done, and our whole field is changing. The point is… this is how we got to ENJOY the academic life during a pandemic! We made lemonade (and several other desserts!) out of the lemons we were handed. New knowledge comes from thinking big and trying new things. Turns out, sometimes you also have to write about those experiences and share them with others.

As emergency physicians, we know we’re good in a crisis. But this experience reminded us that by surrounding ourselves with amazing people, we could get a surprising amount of work done (at record speed) and have a fantastically memorable time along the way. The moral of this story is that when you bring great people together and give them a chance to get to know each other, magic happens. ALiEM Connect happens. And we impact more people than we can possibly meet at the touch of our keyboards. We are so grateful for the chance to work alongside all the wonderful people at each of our institutions every day. Still, also, we are indebted to those who are our digital family. Thank you to all of you who make initiatives like ALiEM Connect possible. Academic life in emergency medicine is all about bringing a great team together.

So is the ALiEM team.

ALiEM Stands in Solidarity with Our Asian American and Pacific Islander (AAPI) Community

We at ALiEM wholeheartedly condemn the xenophobia, intolerance, and hate crimes directed towards Asians and the Asian American and Pacific Islander (AAPI) communities. Recent events spurred by the COVID-19 pandemic are hurtful, “othering,” and simply unacceptable.

Anti-Asian hate crimes across the country since the onset of the COVID-19 pandemic have increased 833% in 2020, compared to 2019, in cities across the United States [1]. This heart-breaking trend of violent assaults against individuals in the AAPI community is misguided and counter to the healing and building that our country direly needs as a result of the global pandemic.

Last week’s shootings in the Atlanta area that claimed the lives of eight people, including six Asian women, have had devastating effects on the AAPI community. For some, it has sparked recollections of previous incidences of bias they themselves have experienced. For others, it has been a call to action, on how to be better advocates and allies for all people of color.

We stand in solidarity with our AAPI communities and allies. These hate crimes continue to highlight the ongoing and longstanding structural anti-Asian and anti-immigrant racism in our country. Each of us has the capacity to show kindness, compassion, and respect for one another. Each of us has the capacity to stand up for those tormented and racialized. Let us work together to overcome the hate and bigotry that plague our nation.

 

What can you do to be an ally?

 

References

  1. VOA News: Hate Crimes Targeting Asian Americans Spiked by 150% in Major US Cities

AAPI solidarity statement

By |2021-03-28T10:19:46-07:00Mar 26, 2021|Life, Public Health|

Silence is not an option: Addressing structural racism in medical education

racismThe year 2020 has been a year of upheaval. The COVID pandemic revealed disparities in healthcare and its effects on marginalized groups such as the Black community. The pervasive effects of structural racism affect all of us, including in medical education. We cannot and must not remain silent. As we honor Juneteenth, #BlackLivesMatter, and #WhiteCoatsforBlackLives, let us reflect on ways we can address racial injustice in our direct environment.

(more…)

By |2020-06-19T08:37:15-07:00Jun 19, 2020|Academic, Emergency Medicine, Life|

Trick of the Trade: Angiocatheter for manual aspiration of priapism

needle position for priapism

A 25-year-old man presents with 6 hours of penile pain and swelling after recreational penile injection of Trimix (alprostadil, papaverine, and phentolamine). He denies any history of sickle cell disease or penile trauma. On exam, he is in moderate discomfort and has a tumescent penis with a soft glans. You suspect the patient is suffering from ischemic, low-flow priapism. Manual compression and ice application have been attempted with no significant improvement in the patient’s clinical status.

(more…)

By |2020-05-13T11:19:13-07:00Jun 10, 2020|Genitourinary, Tricks of the Trade|
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