Tricks of the Trade: Finding the wandering contact lens
Contact lens wearers are familiar with the phenomenon of the wandering lens. What should you do if you can’t visualize the contact lens of a patient, who presents with a “lost contact lens” in the eye? You have the patient look in all directions and you evert the eyelid, but still no contact lens can be found. The patient swears that it’s there because of the painful foreign-body sensation. [+]
Diagnoses that sound alike
Emergency Medicine is as much about taking care of undifferentiated patients as it is about naming specific signs, symptoms and diagnoses. After 10 years of medical training I’ve noticed that there are a few diseases that require us to stop and think a bit. In particular I’m thinking about conditions that share these features: They sound-alike, look-alike, or share words or roots of words They affect a specific organ or part of the body They have very different etiologies, implications, prognosis and treatment The two sets of diagnoses that I encounter most frequently with this problem are Mesenteric Ischemia (or [+]
Paucis Verbis card: Subarachnoid hemorrhage high-risk characteristics
In Wednesday's post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada. We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it's difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don't miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache. In this 5-year multicenter study, the investigators [+]
Paucis Verbis card: Cervical spine imaging rules
There is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice. The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients. Sensitivity (%) Specificity (%) NEXUS 99.6 12.6 CCR 99.4 45.1 NEXUS National Emergency X-radiography Utilization Study A patient’s neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are [+]
Trick of the Trade: Self-Reflection
After a shift, we often review the day’s case with our learners. We sometimes ask them to self-reflect. I often used Demian’s ‘Plus/Delta’ approach and ask ‘What did you like /what would you change?’ This approach works well mostly. But, when the answer is ‘I don’t think I would change anything’, it is hard to target teaching and feedback to the learner’s need. [+]
Article review: Consensus methodologies in qualitative research
What types of methodologies are used to develop a consensus statement? I’m in the midst of helping to write a consensus statement manuscript in education and ran into this great review article. It’s from the British Medical Journal in 1995. Basically, there are 2 general types of methodologies: Delphi Process Nominal Group Technique [+]
Paucis Verbis card: Dysphagia
Dyphagia is a disorder of swallowing. It actually occurs in up to 10% of adults older than 50 years old. How can you determine the most likely causes for dysphagia? The secret is to obtain a thorough history and using the algorithm below, which I find really helpful from a review article in American Family Physician. How do you read the figure? Determine first if patient has oropharyngeal vs esophageal dysphagia. Determine if mechanical (problem is solid foods only) vs neuromuscular (problem with liquids and solids)is more likely. Tip: Medications can cause dysphagia from esophageal mucosal injury or reduced lower [+]
Hot off the press: Medical Student Educator’s Handbook
It’s finally here! The second edition to the Medical Student Educator’s Handbook is finished. Here’s the info from the CDEM website: [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief [+]
Trick of the Trade: Laryngospasm notch maneuver
What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED? Answer = 0.3% A child with laryngospasm can be a scary thing to manage. There’s no way to predict whether a child is going to get it. You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don’t work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first? [+]
Pros and Cons of Social Media Use in Medicine
The American Medical Association (AMA) just released a policy on Social Media and Medical Professionalism. It focuses more on the negative aspects of social media, and much can be averted by just using common sense: [+]