One of my favorite blogs, Better in Emergency Medicine, by Dr. Rob Cooney reviewed the 1991 article entitled “The Ten Commandments in Emergency Medicine”. These commandments are timeless and still hold true today. Rob gives a helpful review of each commandment’s relevance in today’s ED.
I’ve heard of underwater basketweaving, but underwater ultrasonography?
Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient’s extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient’s skin and transducer. What’s a quicker and easier way to create some distance yet preserve image quality?
Submerse both the body part and the ultrasound transducer under water.
For this “bath water technique”, start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.
This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient’s wound.
Reference
Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267
If you have not heard of TED videos, I highly encourage you to view them. They are short, inspirational, and professional talks by leaders, scientists, and artists, who focus on bringing together the 3 worlds of Technology, Entertainment, and Design.
Because many of these videos focus primarily on education, TED has just built a new online community of educators called the “TED-Ed Brain Trust“. The mission is to bring together “the expertise of visionary educators, students, organizations, filmmakers and other creative professionals to guide, galvanize and ultimately lead this exciting new initiative.”
Let’s rethink how we design our Powerpoint slides. Let’s create design principles using Mayer’s cognitive theory of multimedia learning.
In a nutshell, people learn through two channels — words and images. This dual-channel theory suggests that people process auditory and visual stimuli separately. Each channel requires time to process information before merge into a cohesive cognitive concept.
Do no harm.
We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?
Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don’t have a history of a GI bleed or peptic ulcer.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
You are super-excited to get your first real job as an emergency physician after residency. Then this immediately turns into a nauseating, super-terrified feeling, right?After posting two entries to help medical students do well on their EM clerkship rotation, a commenter suggested that I provide a list of tips for doing well as a new EM attending physician. Although there is slightly variation for community versus academic faculty, many of the basic tenets hold true:
One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness.