About Michelle Lin, MD

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

Paucis Verbis: Pulmonary Embolism Clinical Prediction Rules

“Should I get a D-Dimer test or CT chest angiogram on my patient with atypical chest pain to rule-out a pulmonary embolism?” This is a common question asked by emergency physicians on a routine basis.

Here are 3 clinical prediction rules: PERC, Wells, and Simplified Geneva Score. Personally, I’ve never used the Geneva Score, but it’s worth looking at.

A WORD of CAUTION

These rules should be used with caution, because none of these scoring protocols are perfect. For instance, in a recent publication in the Journal of Thrombosis and Haemostasis, the authors found that the PERC rule does not actually safely exclude PEs.¹ Big bummer for us clinicians.

PV Card: Pulmonary Embolism Clinical Prediction Rules

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Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Kit Tainter (Mount Sinai PGY-4 EM resident) for coming up with the idea for this card!

Reference

Hugli O, Righini M, Le G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9(2):300-304. [PubMed]

By Michelle Lin, MD|2021-10-13T08:47:00-07:00Jun 3, 2011|ALiEM Cards, Pulmonary|

I have heard of using tea bags under your eyes to reduce puffiness, but to combat odors in the ED?

In my growing list of “Tricks of the Trade” tips for protecting your olfactory nerves (Antacid booties for toxic sock syndrome, aerosolized orange juice, abscess drainage using suction), I got a clinical gem from Dr. James Juarez (Rogue Valley Medical Center in Ashland, OR) after my recent Tricks of the Trade talk at High Risk EM in San Francisco.

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By Michelle Lin, MD|2019-02-19T18:41:48-08:00Jun 1, 2011|Tricks of the Trade|

Article review: Improving case presentations with theater training

“To be or not to be?”

What could be more strange on a medical school curriculum than a theater training course? The authors of this study in Medical Humanities innovatively designed a 1-week elective course to help medical students at Mayo Medical School to improve their case presentation skills in partnership with the Guthrie Theater.

In this pilot course, seven medical students (six 1st year students, one 4th year student) participated. The learning objectives were:

Hear stories: those told by patients, colleagues and in written narratives
Identify the elements of a narrative, and examine stories for narrative structure
Share stories: through case presentations, body movement, storytelling and acting
Present a patient’s story with elements of traditional medical presentation and narrative

Students were evaluated for the following competencies:

The cognitive capacity and flexibility needed to evaluate and acquire reliable clinical information.
The ability to actively and generously observe and listen to another.
An understanding of the components of narrative leading to effective story construction.
A performance sensibility that ensures the delivery of a good story, otherwise known as stage presence.
The finesse to communicate empathically with a patient to create an environment in which she or he feels safe, satisfied and heard.

Eleven sessions, over 25 hours, comprised of the following topics:

Improvisation activities
Introduction to case presentations
Body language – contact improvisation
Performance of story
Neutral dialogue and elements of a narrative
Narrative in context – what’s lost, what’s gained?
Listening with a neutral mask
Storytelling
Writing and presenting case histories
The art of personal monologue
Final presentations with professional critique

Survey responses uniformly found that students valued this creative, non-traditional approach to learning about interpersonal communications and oral presentations. The art of focused storytelling to an audience is exactly what physicians do every day when presenting clinical cases.

Reference
Hammer RR, et al. Telling the Patient’s Story: using theatre training to improve case presentation skills. Medical humanities. 2011, 37(1), 18-22. PMID: 21593246
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By Michelle Lin, MD|2016-11-11T18:53:06-08:00May 30, 2011|Education Articles, Medical Education|

Paucis Verbis: Outpatient treatment for diverticulitis

The classic prior teaching for the treatment of diverticulitis includes:

Hospital admission
Bowel rest (NPO)
IV fluids
Broad spectrum IV antibiotics

Do ALL patients need to be admitted? There is some early literature suggesting that there is a small sub-population who fare well with outpatient treatment.

This article from Annals of EM in the “Best Available Evidence” series summarizes the existing literature well.

PV Card: Diverticulitis

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

Word of caution

This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I’d still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.

Still it’s nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.

Reference

Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of Emergency Medicine. 2011;57(6):600-602. doi: 10.1016/j.annemergmed.2010.11.008

By Michelle Lin, MD|2021-10-13T08:49:38-07:00May 27, 2011|ALiEM Cards, Gastrointestinal|

Trick of the Trade: Ring removal from a finger

A patient presents with a swollen finger after falling and fracturing it. The patient is more distraught by the fact that she can’t get the ring off her finger. She implores you not to cut the ring off.

There are textbook chapters written about tightly wrapping the digit with string from distal-to-proximal and sliding the string under the ring. Theoretically, the provider can pull and unwind the proximal end of the string to gradually coax the ring over the coils of string.

I have personally found little luck with this maneuver.

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By Michelle Lin, MD|2016-11-11T18:53:07-08:00May 25, 2011|Tricks of the Trade|

What do these 3 people have in common?

Lucille Ball (comedienne)
Jonathan Larson (wrote the musical “Rent”)
John Ritter (comedian)

They all died from an aortic dissection. We commonly consider this diagnosis for Emergency Department patients presenting with severe chest pain. There is an International Registry on Aortic Dissection which published a retrospective, descriptive study of 464 patients with dissections.

I find this list helpful, because it illustrates the fact that the classic signs and symptoms aren’t actually very common. Here are some scary examples:

A pulse deficit in the carotid, brachial, and femoral arteries is only present 15% of the time.
A tearing or ripping quality of pain is present in only 50% of patients.
Not all patients have a widened mediastinum or abnormal aortic contour (only 78.7%).

PV Card: Aortic Dissection

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

Reference

Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA. 2000;283(7):897. doi: 10.1001/jama.283.7.897

By Michelle Lin, MD|2021-10-13T08:51:53-07:00May 20, 2011|ALiEM Cards, Cardiovascular|