About Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

Trick of the Trade: Recognizing eyedrop bottles by color

Have you ever wondered why prescription eyedrops have different color bottle caps? Did you know that the American Academy of Ophthalmology (AAO) has a policy to color-code topical ocular medication bottles caps?

Why was this needed?

“The Academy’s policy on color coding of eyedrop drug caps was prompted by reports to the Academy and the National Registry of Drug-Induced Ocular Side Effects of serious adverse events resulting from patient difficulty in distinguishing between various ocular medications. With input from the pharmaceutical industry and the Food and Drug Administration (FDA), the Academy’s Committee on Drugs developed a uniform color-coding system.” — AAO policy statement

This totally makes sense. I would think the highest-risk population to mix up medications are those with vision problems. The colors help serve as an safeguard against error.

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By Michelle Lin, MD|2016-11-11T18:41:10-08:00Feb 12, 2013|Ophthalmology, Tricks of the Trade|

When would you obtain a CT for a pediatric patient who sustained a head injury? Watch this nice 11-minute video review by Dr. Raul Patwari, discussing the 2009 Lancet PECARN study.

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By Michelle Lin, MD|2019-02-19T18:07:48-08:00Feb 10, 2013|Orthopedic, Patwari Videos, Pediatrics, Radiology|

Trick of Trade: Needle foreign body removal

An IV drug user accidentally breaks off a 25-gauge needle in his/her forearm and presents to your ED for needle foreign body removal. How can you minimize the degree of trauma to the patient? How can you minimize the number of incisions made in order to find and remove this “needle in a haystack”?

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By Michelle Lin, MD|2019-01-28T22:06:45-08:00Feb 5, 2013|Tricks of the Trade|

Patwari Academy videos: Toxicology

What is your approach to the poisoned patient? Listen to these 4 videos by Dr. Rahul Patwari to build your foundation of knowledge in toxicology.

Introduction
Toxidromes
Testing
Decontamination

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By Michelle Lin, MD|2019-01-28T22:06:55-08:00Feb 3, 2013|Patwari Videos, Tox & Medications|

PV card: VBG versus ABG

You obtain a venous blood gas (VBG) on a patient with a COPD exacerbation because you are concerned about hypercarbia. You get a value of 55 mmHg. How correlative is that compared to an arterial blood gas (ABG). There has been a lot of literature on how well the pH correlates between the ABG and VBG but what about pCO2?

A small study (n=89) from 2012¹ found that with a cutoff of pCO2 < 45 mmHg, the venous pCO2 is 100% sensitive in ruling out arterial hypercarbia. When the pCO2 was ≥ 45 mmHg, the VBG was less correlative.

Below is a review by Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob Bryant (Intermountain Medical Center in Utah) of the VBG vs ABG correlative data, along with a proposed algorithm on what to do with patients with COPD exacerbation.

What is your practice with an elevated pCO2 value on VBG?

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Adapted from [1–5]
Go to ALiEM (PV) Cards for more resources.

Updated 1/31/13 at 2 pm PST:

Changed range of pH correlation between VBG and ABG = 0.03-0.04
Was typo in abstract of Kelly et al article.² Stated difference between pHs was 0.4, rather than 0.04 as described in main results text.

References

McCanny P, Bennett K, Staunton P, McMahon G. Venous vs arterial blood gases in the assessment of patients presenting with an exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med. 2012;30(6):896-900. [PubMed]
Kelly A, McAlpine R, Kyle E. Venous pH can safely replace arterial pH in the initial evaluation of patients in the emergency department. Emerg Med J. 2001;18(5):340-342. [PubMed]
Ma O, Rush M, Godfrey M, Gaddis G. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003;10(8):836-841. [PubMed]
Middleton P, Kelly A, Brown J, Robertson M. Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emerg Med J. 2006;23(8):622-624. [PubMed]
Koul P, Khan U, Wani A, et al. Comparison and agreement between venous and arterial gas analysis in cardiopulmonary patients in Kashmir valley of the Indian subcontinent. Ann Thorac Med. 2011;6(1):33-37. [PubMed]

By Michelle Lin, MD|2021-10-08T09:26:47-07:00Jan 31, 2013|ALiEM Cards, Endocrine-Metabolic, Pulmonary|

Patwari Academy videos: Demystifiying how ECGs work

As a nice segue from the Low Risk Chest Pain videos, below is a 3-part series on Demystifying the Electrocardiogram by Dr. Rahul Patwari. It takes talent to make the complex simple.
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By Michelle Lin, MD|2016-11-11T10:08:09-08:00Jan 27, 2013|Cardiovascular, ECG, Patwari Videos|

PV card: Diagnosis of DVT (ACCP guidelines)

A patient presents with an asymmetric leg with trace pitting edema in the affected leg. What is your diagnostic approach to such a patient? What is the role of D-dimer and ultrasound (U/S)? Does this match the 2012 American College of Chest Physicians (ACCP) guidelines?

The first step is to determine your patient’s pretest probability because the recommendations vary based on risk. I can tell you that many ED patients come in with a Wells score of 1-2, which places them in the “moderate pretest probability” category. There are 2 approaches you can take based on the availability of resources at your site (high-sensitivity D-dimer or U/S) and the patient’s comorbidities. Are you referring your patient for a repeat outpatient ultrasound, if warranted?Walk through various patient scenarios to see how the D-Dimer and U/S come into play.

PV Card: Diagnosting DVT – ACCP Evidence Based Guidelines

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Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Jason West (EM resident at Jacobi/Montefiore) for this card idea and deciphering the complex recommendations from the publication.

Reference

Bates S, Jaeschke R, Stevens S, et al. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e351S-418S. [PubMed]

By Michelle Lin, MD|2021-10-08T09:29:18-07:00Jan 24, 2013|ALiEM Cards, Cardiovascular|

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