Twitter

Firstly we got everyone to join Twitter. You can do this via the website or via an app on your computer or phone. For interest sake I use TweetDeck through Chrome on my computer and use Twittelator Pro on my iPhone.

I suggested that when you join twitter you should put a little of biographical information about yourself. People are more likely to interact with you if they know something about you. There are a lot of fake, spam Twitter accounts and having some info on someone helps people to trust you.

I suggest having a profile picture as well rather than the default, anonymous egg.

For example here’s mine:

Follow People 

When you get started I suggest you follow a few key people to start with. Here’s 5 to get you started:

@sandnsurf

@precordialthump

@cliffreid

@broomedocs

@M_Lin

The more interact, post and reply to people, the better your twitter experience will be. We don’t bite honestly, we loved being asked questions on Twitter.

Follow Lists

You can also follow lists, either other peoples or your own that you create. This is a good way to ensure that you’re spending your time well on Twitter. If you make a list of people who consistently tweet high value info then you’ll not be bored by dross about people’s dinner…

Here’s a list I have of “medical tweeters”

Follow Hashtags

Hashtags [words beginning with the '#' symbol] are good ways to join conversations together. My favourite hashtag is #FOAMed, this is a consistent conversation about FOAM resources. You can type #FOAMed into the twitter website or onto your twitter app to find it.

NB, on a mac the # symbol is produced by pressing the ‘option/alt’ key and ’3′ together.

If you want more twitter basics then check out momthisishowtwitterworks.com

Podcasts

I think the key is to get your podcasts on your smartphone. That way wherever you are yo can listen to them. It’s much more important to have them on your phone your computer in that sense.

The basic ‘podcasts‘ app from apple on the iphone is a reasonable place to start.

Once downloaded, start the app and click the ‘store’ button.

Once you’re in the store, search for whatever it is you’re interested in.

Once you find a podcast you want to subscribe too, just click on the subscribe button. Every time a new podcast is released it should download automatically to your phone.

LITFL have a great list of podcasts and a searchable database too, if you need to find more.

Feed Reader

Most of the FOAM websites produce new material on a regular basis. To save you having to visit the site to check if new amterial has been released, you can use something called a feed reader that will collect all the new material from all your favourite websites in one place. I used to recommend Google Reader but it’s shutting down in July 2013 and I’m now suggesting feedly as a good alternative.

Once you’ve added feedly to your internet browser or downloaded the app to your phone or tablet then you can add the websites you’re interested by either clicking on the RSS symbol on the website

or copying and pasting the website URL into the search box

The mobile app is kept in sync with your computer and is set out in a similar easy to use way.

If you’re looking for one place to look for all the best in FOAM then check out Kane Guthrie’s LITFL review.

Blogs

So say you’re keen to start putting out your own FOAM material, then starting a blog is a good way to start. Here’s the website we set up at the workshop in 15 minutes.

This is what the ‘dashboard’; the construction site of the website looks like.

This is all free and easy to do via wordpress.

Google Plus

We only mentioned this briefly but I said I thought it was a brilliant platform for FOAMed but unfortunately under utilised. Its best features are probable communities [check out ECG+ and the EMCrit community] and the google hangouts. Here’s a nice example of google hangouts being used to stream a conference live.

Or here as a conversation between experts discussing some medical papers. Saves all the hassle (but not quite as much fun) of actually meeting up.

Screencasts

Due to technical issues we couldn’t quite pull this off live at the workshop but a screencast is typically a recording of what’s on your screen with a voice over. It’s a great way to share a lecture you’ve prepared with lots of other people. Once the video file is made you can upload it to YouTube, Vimeo or even better GMEP for other people to see.

Screenr.com let you record screencasts without having to download a separate app but I do a fair bit of this so I use one called screenflow.

As an example here’s a screencast of the talk I gave at the conference.

Lastly the app I used for displaying my iPhone screen was one called Reflector which is $12 but a really, really well put together app that lots of people recommended but I first found via Haney Mallemat and my brother the software developer.

UPDATE: Michelle Lin has just published a nice piece here outlining some social media basics. There’s a video to go with it too

UPDATE 2:

For those interested in EMS specific FOAM then here’s some useful sites [H/T to @amboFOAM for some of these]

• AmboFOAM
• Standing Orders
• Post 88
• EMS 12 LEAD

The post Workshop for EMS Gathering appeared first on Emergency Medicine Ireland.

Just a little shout out to a conference I’m speaking at next week.

The Irish EMS gathering is a conference aimed at pre-hospital specialists being held in Co Kerry, way over there in the south west of Ireland. The program (see morning sessions, afternoon sessions and evening sessions) is a good mix of academic and leisure activities so it’s definitely worth checking out.

They were foolish enough to let me talk on social media and the auld Twitter malarkey which is a real honour for me. I’m speaking on Wednesday morning and hopefully running a workshop on the wednesday afternoon as an introduction/development session on how to use the old interwebs to learn and share effectively.

If anyone is going please stop by and say hello, it’d be lovely to meet you.

As far as I’m aware they’re still open to registrations and I’d highly encourage you to come along.

I’ll endeavour, as usual to do a screencast of my presentation for the rest of you all to enjoy/criticise/abuse…

The post EMS Gathering – Killarney, Ireland. May 15th-16th 2013 appeared first on Emergency Medicine Ireland.

She’d been in the department overnight, got some fluids, bloods and an ECG. The ECG was said to be normal.

I went and chatted to the patient and yes indeed it did sound all very like postural hypotension. I went back and looked at the ECG and did my usual syncope ECG review looking for the following:

• Brugada
• HOCM
• WPW
• intervals – QT and PR

And there it was – a nice big QTc of 550ms staring at me.

I still suspect that postural hypotension was the main cause of her symptoms but it would be a tad on the risky side to call it that in the context of a long QT. K+ and Mg++ were on the low side (3.5 and 0.6) so she got a bit of both and admitted for ECG monitoring.

The interesting bit came in the discussio with admitting doctor who was (for once) interested, enthusiastic and asked about the standing test for Long QT. This was all news to me but effcetively people with a long QT syndrome (LQTS) have an abnormal response in QTc with standing.

In healthy people on standing the heart rate goes up with corresponing shortening of the QT interval. Due to the fact that heart rate goes up more than the QT comes down, the QTc actually goes up slightly,

In LQTS the QTc often goes up substantially.

This paper addresses this concept and while it’s in now waty perfect (ie it examined it in people known to have LQTS which undermines its use as a diagnostic test in undiagnosed QT problems) it suggests that in healthy people an increase in QTc on standing of about 10-15ms is allowed but in LTQS is likely to be in the range of 90-100 ms.

Viskin, Sami, Pieter G Postema, Zahurul A Bhuiyan, Raphael Rosso, Jonathan M Kalman, Jitendra K Vohra, Milton E Guevara-Valdivia, et al. “The Response of the QT Interval to the Brief Tachycardia Provoked by Standing: a Bedside Test for Diagnosing Long QT Syndrome..” Journal of the American College of Cardiology 55, no. 18: 1955–1961. doi:10.1016/j.jacc.2009.12.015. PMID 20116193

METHODS

• the normal response to standing after lying is an increase in HR. This would normally be accompanied by a shortedned QT. In LQTS this apparently isn’t the case
• The intervention was standing and recording QT changes.
• they did this on high risk LQTS (lots of features but no diagnosis as yet) and those who actually had it genetically documented. The controls were healthy relatives of those pts or volunteers (the vast majority)
• took them off Beta blockers for a day then lay them flat 10 mins and stood them up for 5 mins with telemetry.
• blinded investigator performed the measurement had a set part of the trace. Bazzett’s  formula was the main one used.
• excluded the obviously normal and obviously prolonged

RESULTS

• 68 LQTS; 82 controls
• the baseline QTs were 380 v 450 – not diagnositcially different but borderline
• the QT went down in all the normals but less than the RR interval therefore the QTc goes up slightly.
• the QT of those with LQTS didn’t change at all. In some it went up. Or put another way the QTc of the control group went up 13ms while the LQTS patients the QTc went up 89ms

Not something I’m going to be doing every day, but it’s a fairly nice, bedside test that we can apply in the ED.

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First part lives here

You may have to click through to the GMEP site to see the full HD version

PDF of slides

The post Anatomy for Emergency Medicine 027: Basic Anatomy of Abdomen and Pelvic Trauma appeared first on Emergency Medicine Ireland.

Everyone finds neuroanatomy tough, you’re not alone. Most of it doesn’t really concern us in the ED that much. However we will have people attend or be referred with isolated III, IV and VI palsies.

If you understand the basics you can  know when to get worried and scan and admit and to relax and explain to the patient that this will likely improve with time.

First I suggest watching this video from the single best eye teaching source I’ve found [Chris Nickson found it for me of course ]

I also found this paper [via the only neuro blog I read] which covers the anatomy but also some advice on when to image and when not to. This is my basic summary.

In general

• a lot of isolated palsies can be observed as most are vasculopathic and will resolve
• isolated palsies in young people should cause consideration for mass. Non-vasculopathic sixth palsies are relatively high risk here
• the key point is identifying isolated. If they have headache or other signs then it’s not isolated
• temporal arteritis can be involved in all of them, as can myasthenia but there should be other signs/symptoms

III

• if motor only can usually be observed as most will be vasculopathic if the risk factors exist
• if mixed motor and pupil should be imaged
• if pupil only then think about compression

IV

• even traumatic IVs don’t need imaging for ICH (though maybe for fracture)
• head tilt is common along with pupils not at the same level
• some are congenital that have decompensated
• again the vasculopathic ones do quite well
• sub-arach space rarely involved
• isolated non-vasculopathic ones may (with caveats) be observed (unlike VI and III)

VI

• traumatic VI needs a scan
• vasculopathic can be observed
• non-vasculopathic should get scanned (they quote a 25% malignancy rate which seems awful high)
• they oddly don’t mention benign raised ICP as a cause

In the ED it’s not always as straightforward as this as the key is follow up. Depending on your access to neurology/ophthalmology will dictate how you manage them.

The post Cranial Nerve Palsies -III, IV and VI appeared first on Emergency Medicine Ireland.

It’s longer than the usual podcasts so I’ve split into two parts.

Feedback, is as always, welcome.

You may have to click through to the GMEP site to see the full HD version

PDF of slides. 

The post Anatomy for Emergency Medicine 026: Basic Anatomy of Chest Trauma appeared first on Emergency Medicine Ireland.

All hospitals have pretty good policies and procedures about what to do when a staff member gets a needlestick injury. A lot of these patients in the systems I’ve worked in come to the ED out of hours. It’s our responsibility to do a risk assessment and  ensure the appropriate bloods and paperwork are done and in the rare occasion consider PEP.

Where I’m currently working in Dublin has a substantial population of IV drug users and we also receive patients from large prison across the road. It makes for an interesting population of patients. It also results in lots of blood born virus (BBV) exposures in the community setting.

These guidelines [free PDF here] give clear and specific guidance about what to do in each situation. They were put together by a whole bunch of people but there a few emergency physicians involved in the process too so it’s relevant to what we do.

There’s lots of useful info in it but here’s some highlights

• Hep B vaccine is highly effective at preventing infection if given ear;y (preferably within 48hrs) and they suggest a low threshold for giving it in any significant exposure. This is of course good news considering how tremendously infective Hep B is. There is a role for passive immunity from Hep B immunoglobulin but they confine it to “limited circumstances”
• There is no prophylaxis for Hep C (which is a shame considering how easily transmissible it is), however it’s still important to get them tested and followed up as early treatment is highly effective at clearing the virus.
• HIV PEP should only be considered within 72 hours of the injury (hence the importance of the role of the ED when the ID guys are off for the weekend). To know when to give it requires a little sociology. Given the local population where I work, the majority of needlestick injuries are going to be sourced from IVDU and are fairly high risk so we use a reasonable amount of HIV PEP in these cases. Of note the number of people from occupational exposures (ie healthcare workers) who have seroconverted since the introduction of PEP is almost zero.
• Don’t forget tetanus
• Bites: “A recipient of a bite that breaches the skin but with no visible source blood does not require any follow-up from the point of view of HIV and HCV.” They do suggest Hep B
• Sexual exposure: In the case of sexual assault, Ireland has Sexual Assault Treatment Units (SATU) available but they may occasionally end up in your ED and the guidelines have a good algorithm for management.

There are lots of useful numbers to give you and your patient an idea of what the risk actually is.

And finally the tail end of the document has patient information leaflets, so that you can give the patient something home with them so they don’t have to remember all the information you just threw at them.

I’ve used the guidelines about once a week since I found them and I keep them as a PDF file on my phone so I can access them in work.

As a final plug there’s a one day conference launching the guidelines in Dublin on 19th April 2013 [Details below]

PEP Conference

I’d be interested in how the guidelines match up to practice elsewhere in the world. If you’ve any thoughts leave them in the comments.

Conflicts of interest:

I have no financial or academic ties to these guidelines and I had no part in the development of them, however I do know some of the people who were. This post simply reflects the fact that I think they’re pretty useful for clinical practice.

UPDATE:

Graham Walker points out that there’s a nice risk estimator on the MD Calc site that’s worth checking out too.

The post Post-Exposure Prophylaxis Guidelines for Ireland appeared first on Emergency Medicine Ireland.

Hospitals are busy places. We have no space, no beds, no staff and inevitably less money to make this all happen. This is the situation we have.

We’re fairly pragmatic folks so we find ways to manage the work more efficiently and try and do more as an out patient or involve things like ADPs (accelerated diagnostic protocols)

But when we get slammed and have more admitted patients than you have trolleys to put them on then the system grinds to a halt and you can’t assess treat and admit/discharge anyone new.

In Stony Brook in New York, the hospital (and that’s the important bit, not just the ED) decided that when the ED was choked that they could put some of the stable patients as extras in the hallways of the wards. You can imagine what the ward staff thought of that.

This is a brief paper reviewing their experience.

Viccellio, Asa, Carolyn Santora, Adam J Singer, Henry C Thode, and Mark C Henry. “The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: a 4-Year Experience..” Annals of Emergency Medicine 54, no. 4 (October 2009): 487–491. doi:10.1016/j.annemergmed.2009.03.005. PMID 19345442

This is a review of patient flow effectively and not a trial in any prospective sense. All they wanted to show was that this was happening and what the effects were.

It is not the highest quality science and does not claim to be.

RESULTS

• 25% of those assigned to a hallway bed actually got a proper bed immediately
• another 25% got a proper bed within an hour
• the rest got a proper bed within 8 hrs.

THOUGHTS

Your hospital probably has more beds than they say they do. Spreading the crowding from one place to the whole hospital spreads the moral and professional responsibility to a hospital wide problem. It’s remarkable how that motivates resources.

Importantly it must be realised that this is no panacea for a poorly run hospital. In fact every time a hospital implements something like this it’s a sign that something is deeply wrong. However it can alleviate a crisis.

The Irish Association has a nice statement on FCPs. And indeed a nice EMJ paper on the same too.

The post Full Capacity Protocols appeared first on Emergency Medicine Ireland.

This got a very amount of Twitter attention when it came out as it was a bit of a headline grabber:

Shanafelt, Tait D, Sonja Boone, Litjen Tan, Lotte N Dyrbye, Wayne Sotile, Daniel Satele, Colin P West, Jeff Sloan, and Michael R Oreskovich. “Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population..” Archives of Internal Medicine (August 19, 2012): 1–9. doi:10.1001/archinternmed.2012.3199. PMID 22911330

First a quick run through of the study and then some thoughts

METHODS

• this was a massive survey of the AMA register of doctors compared with the general population. It was done effectively by mass emailing
• the survey used the “gold standard” of burnout: the Maslach Burnout Inventory
  • the only problem here is that it’s a bit of a cumbersome tool so they let the docs fill in the whole survey whereas Joe Bloggs only filled in what the authors state are the predictive bits of the survey. They say that doing this has been studied before and is kosher but there you go…

RESULTS

• only a 26% (7000/27000) response rate in the docs. A response rate of somewhere closer to 70% is considered important as it’s giving a much more representative of the people you’re surveying. If you think about it could be only the pissed off, grumpy docs answering the survey. Or maybe even the opposite and only the calm and cool docs with lots of free time filled it out
• bottom line was that a lot of docs feel overworked and burnt out. And this is higher than the general population
• the people with the highest symptoms of burn out were the EM docs. By a clear country mile it seemed. We were much better than the surgeons in terms of work-life balance but despite this we were still burnt out.

THOUGHTS

I think this is vitally important stuff.

Emergency Medicine is like a puppy – it’s for life not just for Christmas but it seems increasingly both from my own anecdotal experience and now represented in study form in various settings that we’re going to have real difficulty keeping docs in the specialty.

In the US there are comparatively huge numbers of trained Emergency Physicians compared with the UK/Irish model. These guys work shift patterns often for their entire career. They are well paid and work reasonable hours (I was quoted that 30 hrs a week was an average for an EP in the US – can anyone corroborate this?) Despite their resonable work life balance these guys are really burnt out.

Now the UK/Irish model is a service delivered by trainees and non-board certified EPs, (the “sickest looked after by the thickest” as some have joked) these guys are paid less and work more hours than fully trained EPs, of whom we have vanishingly few. Just imagine how much more burn out might apply to those docs who deliver hands on emergency care day in, day out (or night in, night out)…

As I enter my ninth year since graduation from med school with no clear end in sight to my training (largely my own fault I’ll admit) the importance of work-life balance and the threat of burn out becomes more and more apparent. Workforce planning is one of the biggest problems (along with overcrowding) that EM has to face in this part of the world, but if we are to address it in any way we must address sustainability and burn out.

update:

Graham Walker did a survey for EM News on burnout that’s worth a read

http://mobile.journals.lww.com/em-news/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2013&issue=03000&article=00008

The post EM docs are more burnt out than most but none of us are great… appeared first on Emergency Medicine Ireland.

Twitter was a big thing at the conference and a few of us, (myself, Cadogan and John Cronin) had the idea of documenting the use of new media at the conference. We got a few other folk involved, set up some databases and this publication was the result.

It’s not the highest science in the world, but it’s a useful piece to document the rise of online platforms for teaching and involving other people

I’m aware of the irony of a paper on FOAMed being neither free nor open access but as per the EMJ publishing license I’m allowed to share the pdf file with up to 100 of you, so if you can’t get access to the file send me an email and I can get you a copy. I’m also allowed to publish the text of the manuscript which I’ve embedded below as a google doc (if it doesn’t load just refresh the page)

Thanks again to Audun at Symplur.com who provided the awesome “network centrality analysis” as a way of visualising how the conversation at ICEM 2012 happened.

If anyone is keen to do similar studies on some of the upcoming or more recent EM conferences then I’d love to hear from you.

Feedback is as ever welcome.

Figure 1: Social media accounts of ICEM 2012 speakers

Figure 2: Content analysis of ICEM 2012 tweets

Figure 3: Network Centrality Analysis

The post EMJ Publication: Impact of Social Media at ICEM2012 appeared first on Emergency Medicine Ireland.