gmergency!

Nurses and Bowel Sounds

Never understood why nurses document “bowel sounds in all four quadrants.” Can anyone explain?

(Source: whatshouldwecallnursing)

Kaiser Grand Rounds February 1, 2013

Hello Kaiser SF!

I told you that I’d publish a list of all my references, so here we go:

Meta

I made my talk using Keynote. I controlled it using Apple’s Keynote Remote on my iPhone.

Disclosures

I develop MDCalc and theNNT.

Tumblr

Uhm, you’re looking at my Tumblr blog right now.

Memes

A nice big list of Internet memes, from Wikipedia. Quickmeme is how I captioned my own memes for the talk. One does not simply walk into Mordor.

Examples of The Old and the New

Caroline Hampton Halsted: the first to use rubber gloves in the operating room was a fascinating read, and provided me with the Aseptic technique history I used, and who knew — the BMJ reprinted Lister’s seminal work, Antiseptic Principle in the Practice of Surgery.

Here’s Scott Weingart’s post on DSI and his article (that took over a year to get published in print!) from JEM, Preoxygenation, Reoxygenation, and Delayed Sequence Intubation in the Emergency Department (PubMed).

Best Use for a Bougie started from our Twitter conversation and then also became Michelle Lin’s Trick of the Trade.

Joel Topf - Kidney Boy - recount the story of D5W.

Seth Trueger (@mdaware), Scott Weingart (@emcrit), Chris Nickson (@precordialthump), high-quality medical education, emergency medicine (@HQMedEd), Michelle Lin (@M_Lin) and Ryan Radecki (@emlitofnote) all contributed to the Twitter conversation.

History of Medicine

The Becker Exhibits at Wash U provided me with images and information on the history of medical literature and journals. Stephen Abrahamson wrote a great article on CME: Research in Continuing Medical Education. An Historical Review.

Peer Review Concerns

There are a number of papers discussing and criticizing peer review; they include the papers I referenced in my talk: Quantitative analysis of sponsorship bias in economic studies of antidepressants and Classical peer review: an empty gun.

Cost of Journals

Harvard can’t afford journals

The Origins of FOAMed

FOAM Started Site FOAMed Search on Twitter

The Blogs

• Life in the Fast Lane
• Jen Gunter’s Blog
• GeriPal
• Wachter’s World
• Wachter and Verghese’s JAMA Article

The Podcasts

• JAMA Podcast
• Persiflagers Infectious Disease Puscast
• Evidence-Based Therapeutics Podcast
• SCCM Podcast

The Apps (iTunes Store Links)

• Pedi-Stat
• EyeChart
• Nerve Whiz
• EyeHandbook
• iRadiology
• 1 Minute Ultrasound

Video Resources

• HQMedEd
• Procedurettes
• Larry Mellick’s Youtube Procedures
• Youtube Epley Maneuver
• Rahul Patwari’s Med School Youtube Videos
• NEJM Procedure Videos

Social Media Guidelines

I used this great post from the Mayo Clinic’s Social Media blog. * Kaiser Social Media Guidelines/Policy

Other Tools I Didn’t Get To

• Google Reader
• Google Scholar
• Pubget
• You can subscribe the University of Maryland’s Emergency Medicine pearl here.

In Your Daily Practice

• The Captain Morgan Hip Reduction Technique Videos
• TheNNT’s Minor Head Injury in Adults in the Emergency Department
• The UMEM Topic list

Final Thoughts

• Dissemination of health information through social networks: twitter and antibiotics.
• Submit a case to Scott Weingart and EMCrit

The Click of Medicine

Ryan Radecki’s post got me in a tizzy, a tizzy I’ve been meaning to write about for awhile now, where he talks about validation of the Vancouver Chest Pain Rule; it also ties in nicely with my thoughts on this whole “CT Coronary Angio” NEJM article that’s getting all this buzz, too.

Mel Herbert said this before, and I’m going to say it a little bit differently: we’re sadly moving from the art of medicine to the click of medicine.

Let me explain.

I worry that we as a specialty (Emergency Medicine) are heading toward being as mind-numbing as the trauma services are nowadays:

• You have trauma? You get pan scan.
• You have chest pain? You get troponin.

Obviously there are other causes of chest pain besides acute coronary syndrome (more on that in another post), but once you’ve gotten to a point with the patient that you think you’re down to ACS vs. other atypical weird chest pain you can’t diagnose in the ED but is not life threatening (esophageal spasm, GERD, anxiety, etc), it’s so damn easy to just “Click: EKG, Troponin” (and we’re all reasonably worried about missing an MI for a whole host of reasons) that we just click, without considering pre-test probability in any of this.

So let’s compare these two articles:

You’ll notice that the Vancouver Rule got people to less than 2% risk, which is really, really good — and that with troponins, probably would have been even better.

The NEJM article also had “good” outcomes. But you’ll notice that these people got into the study if they were 40-74, and the Emergency Physician felt like they needed a workup for ACS. That’s the stinker, right there. Have we all just gone crazy (I’m included in the “we” here, too) and decided that everyone needs a workup for ACS? You take a low risk population (negative troponin, non-ischemic EKG, not a good story for ACS), and no matter what test you do on them, you’re not going to find much disease… because they’re low-risk to begin with.

You could take low-risk patients and do a coronary CT on them to decide they don’t have coronary artery disease, but you could also take low-risk patients and apply a silly test to them: you’re low risk if you’ve eaten cheese. (See, it works, because they’re already defined as low risk!)

But it’s just so damn easy to click and order a CT coronary angiogram on them that it’s going to happen to people who didn’t need the test in the first place.

I worry that we’ll start applying this test to low-risk patients — as the NEJM article suggests — and end up first, doing harm. Anyone else feel the same way?