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 card: Pediatric blunt head injury

EpiduralIn this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is Pediatric Blunt Head Trauma.

This a particularly relevant topic given the recent press and discussions about CT irradiation and the cancer risk especially in pediatric patients. It’s also relevant since Dr. Nate Kuppermann (UC Davis) just gave Grand Rounds at our UCSF-SFGH EM residency program. He first-authored a landmark 2009 Lancet article on minor head injury in kids.

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By |2019-01-28T23:47:18-08:00Feb 5, 2010|ALiEM Cards, Pediatrics, Trauma|

Trick of the Trade: Preventing tissue adhesive seepage

Dermabond Tape

As great as tissue adhesives are in wound closure, they come with some risk. For instance, liquid adhesives, such as Dermabond, can “run” and contact undesired areas such as eyelid margins. Careful application of tissue adhesives is critical.

How can you minimize the amount of seepage of tissue adhesive to undesired areas?

Trick of the Trade

Create an impermeable tape barrier

I already mentioned this in an earlier post in July, but I now have more experience with this technique. Here are some recent photos of this trick in action.

  • Cut out a circle from a transparent tape adhesive. In this case, I used a transparent Tegaderm which can be found with peripheral or central line IV kits.
  • Adhere the tape to the patient’s skin primarily along the circular edge to prevent glue seepage under the tape. You don’t need to stick the ENTIRE transparent tape to the patient, unless you want to pull off some eyebrow and eyelid lashes!
  • Apply the tissue adhesive glue over the wound while ensuring that the wound edges are closely approximated. Excess glue will run off onto the tape. You only need to wait a few seconds after glue application before peeling the tape off.
DermabondTapeTrick5blursm
DermabondTapeTrick10blursm

This idea was contributed by Dr. Hagop Afarian (UCSF-Fresno).

Thanks also to my Visual Aid Project photographer, Lourdes Adame, who photographed and consented the patient’s father for these photos. Her speaking fluent Spanish made them feel at ease and understand that we were photographing for educational purposes.

By |2019-02-04T03:35:20-08:00Feb 3, 2010|Tricks of the Trade|

Trick of the trade: Irrigating scalp lacerations

Laceration_Scalp1smThanks to my new-found Emergency Medicine friend in Turkey, Dr. John Fowler has some useful tips about scalp lacerations.

Often patients with scalp lacerations have clotted blood in their hair. While we can irrigate the wound itself (and unavoidably soaking the patient in cold irrigation fluid), a lot of blood remains stuck in their hair. It would be nice if we could completely wash out the blood. This would further allows us to detect occult scalp lacerations.

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By |2019-02-19T18:48:05-08:00Jan 27, 2010|Tricks of the Trade|

Paucis verbis card: The Red Eye

Here is another installment of the Paucis Verbis (In a Few Words) e-card series on the topic of The Red Eye from EM Clinics of North America.

Here are some images:

Keratoconjunctivitis

Epidemic keratoconjunctivitis (note subtle white precipitates over pupil)

BacterialConjunctivitis

Bacterial conjunctivitis (note injection along inferior fornix)

Episcleritis

Episcleritis

Scleritis

Scleritis (note bluish hue of deep scleral vessels)

Glaucoma

Acute angle closure glaucoma (note corneal edema)

PV Card: The Red Eye


Go to the ALiEM Cards site for more resources.

By |2019-01-28T23:45:55-08:00Jan 22, 2010|ALiEM Cards, Ophthalmology|

Trick of the Trade: Modified hair apposition technique

modified hair apposition technique

I got a nice email from Dr. John Fowler from Turkey who recently published a modified version of the Hair Apposition Technique (HAT) trick in the American Journal of Emergency Medicine in 2009.

Read more about the traditional HAT trick.

The HAT trick allows for scalp laceration closure by using scalp hair and tissue adhesive glue. Contraindications to this technique for wound closure include hair strands less than 3 cm, because it is difficult to manually manipulate short hair.

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By |2019-11-29T19:03:44-08:00Jan 20, 2010|Trauma, Tricks of the Trade|

Article review: Feedback in the Emergency Department

FeedbackFeedback is important in teaching and learning.

I am constantly surprised by medical student and resident comments that they rarely receive feedback. In contrast, seemingly on every shift, I hear faculty giving little nuggets of feedback – during the oral presentation, during the resuscitation, after a difficult interaction, etc. There must be some disconnect.

This multi-institutional, survey-based, observational study at 17 EM residency programs asked attending physicians and residents about feedback in the ED. The primary outcome measure was overall satisfaction with feedback.

Results

The response rate was 71% for attendings (373/525) and 60% for residents (356/596). Side note: Survey studies are generally inconclusive if response rates are

There was a statistically significant difference between the feedback satisfaction scores (on scale of 1-10 with 10 being highest satisfaction).

  • Attending physicians: 5.97
  • Resident physicians: 5.29

Furthermore, when evaluating the quality of different aspects of feedback delivery, there were statistically significant differences in the satisfaction ratings between the attendings and residents. Overall, attendings felt more satisfied with feedback delivery on various topics than residents were.

  • Quality of positive feedback (50% attendings, 36% residents)
  • ” of constructive feedback (29% attendings, 22% residents)
  • ” of feedback re: procedural skills (48% attendings, 34% residents)
  • ” of documentation (36% attendings, 28% residents)
  • ” of ED flow management (29% attendings, 21% residents)
  • ” of evidence-based decision making (28% attendings, 18% residents)

What is more interesting to me is the discrepancy between what the attendings and residents perceived in frequency of feedback. Specifically, 42% of attendings stated that feedback delivery was being done on every shift. Contrast this to only 7% of residents who felt the same. Why the disconnect? Is it purely misperception?

In re-reading this article, I wonder how this question was phrased though. Was it indeed perception or fact?

Let’s say there are usually 5 residents per attending shift, and the attending gives feedback every shift to at least 1 person. When surveyed, the attending would answer – “Yes, I give daily feedback”. In contrast, because there are multiple learners, residents may not have received daily feedback. By law of averages, residents would have received feedback every 5 shifts.

The data showing that 42% of attendings and 7% of residents were involved in feedback delivery every shift may actually be true (rather than pure perception). This illustrates the trickiness of designing and writing surveys.

Bottom Line

We should be working to improve positive and constructive feedback delivery in the Emergency Department, despite the various obstacles.

Reference
Yarris L, et al. Attending and resident satisfaction with feedback in the emergency department. Acad Emerg Med. 2009; 16:S76–S8.

Also see previous post on Failing at Feedback in Medical Education.

 

By |2016-11-25T15:43:29-08:00Jan 18, 2010|Education Articles, Medical Education|