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.
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.
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.
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.
We should be working to improve positive and constructive feedback delivery in the Emergency Department, despite the various obstacles.
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.
What do you do in these cases?
- A man on coumadin for atrial fibrillation arrives because he has increased bruising on his skin. He is otherwise asymptomatic. He was told to come to the ED because of a lab result showing INR = 6.
- A woman on coumadin for atrial fibrillation arrives because of melena and hematemesis. She looks extremely sheet-white pale. Her vital signs are surprising normal. Stat labs show a hematocrit of 15 and an INR value that the lab is “unable to calculate” because it is so high.
Updated on 6/1/13: Old PV card revised to reflect the 2012 ACCP guidelines
Remember back in the day when we made simple toys for pediatric patients to focus on during the physical exam? Remember the inflated medical glove +/- a face drawn on it?
I just encountered a FREE iPhone application (Eye Handbook), which has a lot of useful features. I currently only use the Pediatric Fixation animations. They can be found under the “Testing” section. Kids (and often adults too!) become mesmerized and distracted by the cartoon animations.
This is exemplified in a recent multicenter study, which addresses whether attendance at weekly residency conferences correlates with a better in-service training examination (ITE) score. The ITE score was used as an outcome measure, because it correlates with the resident’s likelihood for passing the official ABEM Board Exams. Both tests draw from questions in the Model of the Clinical Practice of Emergency Medicine.