A Lull in the Action

It’s been pretty quiet here and on my Twitter feed for the last few weeks.  In fact, turns out I haven’t done much writing, or even reading, over the last month.  The absurdly long hours of a wonderful MICU month melted into a much needed vacation so that now I feel completely out of the loop and also quite behind on my studies.  Will be catching up on both, soon.

We are in fact still on vacation, but production will resume in a few weeks.  First, will get back to the conclusion to “Let the Junior Intubate?” And then I hope to be adding some more FOAM and conference resources.

Thanks to everyone who continues to check-in.  Please keep an eye on the Twitter feed, subscribe to the blog, or just visit again in a little while…

David

Let the Junior Intubate? Nah… (Part B – Ethics and Such)

For the case intro, See “Let the Junior Intubate? Nah… (Part A)“

In an earlier post I introduced a case that got me thinking about intubating in a training environment.  Specifically, I wondered, how do we decide whether the junior-most or senior-most person in the room should intubate the patient with impending respiratory failure?

O (Big) Brother, Where Art Thou?

When it comes to resident intubation there doesn’t seem to be much guidance from major US EM organizations - CORD, ACEP, SAEM or AAEM.  CORD doesn’t say anything on its website and ACEP’s intubation and training policies focus on billing & documentation.  Though SAEM addresses the issue of student supervision in its Ethics Curriculum it does not offer guidance on gauging resident proficiency in critical procedures.  And the newly proposed Emergency Medicine Milestones help a little, but they cannot be directly translated into practice recommendations (specifically, “PC10. Airway Management”). Even the ACGME’s Emergency Medicine Program Requirements are vague on the subject.

Though concerning, a lack of instruction from professional organizations is not surprising.  Given the varied practice environments and teaching styles across the specialty we are left to our own devices to come up with an answer to the question, “Should the junior resident intubate?”

The Ethics of Trainee Intubation

1. Values-
   1. Beneficence (Remember? You love helping people.)
   2. Non-maleficence (First, do no harm.)
   3. Distributive Justice (Equal distribution of risks and benefits)
   4. Patient Autonomy/Self Determination (In the U.S., the patient almost always has the final say)
2. Stakeholder Perspectives -
   1. Patient: The patient who declares “I don’t want students taking care of me!” thinks she will get better care by avoiding trainees.  While some people believe that trainees expose patients to an increased risk of harm there are others who claim that patients actually benefit from the increased attention paid to them by supervised students and residents.  Nonetheless, in the name of Autonomy, physicians must generally respect this request.  Firstly, we often do not properly inform patients that some of the care in academic centers will be provided by trainees (an a-priori violation of patient autonomy and self-determination).  Secondly, even if the patient provides truly informed consent, he may rescind it at any time.  And yet, by refusing trainees the patient is standing in the way of Distributive Justice; all patients should be equally exposed to the risks and benefits of trainee care, not that this is of any concern to the individual. Finally, it is the physician’s duty to ensure that the person performing the procedure is skilled enough to do so safely in the interest of Beneficence and Non-Maleficence.
   2. Physician:
      1. Learner – Needs to establish proficiency in Emergency Medical procedures while upholding all four patient and society centered values.
      2. Educator – Must supervise the learner while encouraging professional growth. Simultaneously, he needs to continue his own personal growth by managing more complex situations while upholding all four patient and society centered values.
   3. Society: There is little doubt that society as a whole benefits from trainee care. By allowing physicians in training to provide direct patient care society is guaranteeing that everyone will have access to experienced, well educated physicians.  Unless we all conspire to kill and maim the people under our care, there is little risk of trainees violating the values of Beneficence and Non-Maleficence, as pertains to society itself.  And short of continuing training despite society’s demanding that we stop, it would be hard to see how medical training would violate society’s right to Self-Determination. However, Distributive Justice is a little trickier. The benefits and harms of trainee care should be distributed equally across the entire country and through all strata of society and yet data suggest that people who receive care at training institutions are more likely to have Medicaid (public insurance intended for those who cannot otherwise afford medical care) and be non-white.  Also, the EP’s decision to intubate carries with it significant consequences.  Intubation commits a patient to mechanical ventilation and possibly an ICU bed.  Since the requisite specialized nurses, respiratory therapists, vents and beds are all finite resources, this one decision has the potential to impact many other critically ill patients.  The situation becomes even more complicated when the patient is in the end stages of a progressive, terminal condition or when mechanical ventilatory support is deemed medically futile.  In the U.S. Self Determination generally trumps Distributive Justice, and even clinical judgement, and thus physicians may feel forced to perform life-prolonging interventions that will have no effect on clinical trajectory at the expense of other patients.  Thus, it is up to the supervising physician to guide the trainee through this murky ethical dilemma as well.
   4. The Hospital: The ethics of systems and institutions is somewhat different.  The most relevant considerations in this context may be the hospital’s own exposure to harms and benefits through the involvement trainees in emergency medical care.
      1. Quality measures – Complications caused by inexperienced practitioners may directly harm patients, but even if not, they reflect poorly on the institution.
      2. Cost – Trainees may increase cost through unnecessary use of durable and disposable medical supplies related to inexperience, improper preparation, failed attempts, etc.  Also, the presence of trainees may decrease speed or efficiency, increase cost of care, cost of malpractice insurance, or exposure to litigation.
      3. Prestige – The presence of training programs often increases an institution’s prestige in the eyes of the public.
      4. Revenue – Prestige may directly lead to increased referrals and patient volume.  In the U.S. resident training is largely funded by Medicare (a federal entity whose primary mandate is the funding of medical care for those aged 65 and above). Thus, residents and fellows are a source of labor that may increase a hospital’s ability to care for patients that does not significantly drain a hospital’s primary financial resources.

The emergency medical provider must be mindful of all these considerations while considering the best way to stave off death yet again.  And though consent is often assumed in true emergencies, questions of beneficence, non-maleficence, self determination and medical education must guide our care just as much as the clinical presentation itself.

A Little Help From My Friends?

From a patient safety perspective, some people I’ve spoken to insist that the most senior person in the room should always perform the intubation.  Others, more focused on the learner, have told me that the junior-most person should do the procedure, provided that adequate supervision is available. The best answer, as always, probably occupies a happy medium between the two.

Lots of questions and no answers…

Trainees are in the ED to train and patients are there to get quality medical care.  In the interest of balancing the needs of both, the junior-most person should be the one performing any procedure, assuming a few conditions have been met:

1. The trainee has completed adequate RSI and AW training (as defined locally)
2. The trainee has demonstrated proficiency using procedural simulators
3. If this is the first time the supervisor and trainee are working together, the trainee is able to adequately verbalize RSI plans and contingencies with supervisor
4. The supervisor is proficient in advanced AW management and AW rescue
5. The supervisor has been trained in safely managing trainees
6. Patient condition is appropriate for junior intubation

The first 5 conditions are self-explanatory.  In the next and final installment of “Let the Junior Intubate? Nah…” I will summarize the first two parts and attempt to define, using clinical literature, which patients are appropriate for junior intubation and which should only be attempted by the most experienced clinician in the room.

All references will be provided in the final post.

Scouring the web for that FOAMy conference? Search no more!

Seems that there is some outstanding medical conference happening every single day of the week.  Personally, I like following anything related to EM, CC, US, prehospital medicine, clinical ethics and professionalism, med-ed, end of life care and palliative care.  But really, it’s hard to keep it all straight so I recently began a new page entitled (creatively) Conferences.  And since you can’t really tell what kind of FOAM (i.e. free) online resources each conference makes available, I’ve now added a second page – Conference FOAM.

The Conference FOAM page will help you make the most of your conference experience.  Keep an eye on it.  As conferences evolve to embrace those who cannot physically attend (I hope), the page should continue to grow with examples of all the fantastic tools made available to remote participants.  

Wink Wednesday #006 – Friday edition…

Logging new and noteworthy linkage from the endless Twitter feed, and other ephemera of the past week.  But first, some thoughts from Patrick Gilbreth and Manrique Umana:

I feel Canadian. Sending people home to live out course of disease in dignified fashion. Will always feel wrong but it's right #comfortcare—
Patrick Gilbreth (@patrickgilbreth) February 15, 2013

@umanamd Even now, even when I see pt dying of natural causes at right time, when they're in ER, I feel need to intervene. It's ok to die!—
Patrick Gilbreth (@patrickgilbreth) February 16, 2013

Now, for the meat of it:

• AAEM2013 just concluded – find all the Tweets, storified, by @MBond007 here.
• Ethics, Med-Ed and Doctoring
  • Do Oncologists Lie to Their Patients? Hopetimism…
  • Can a novel med school curriculum improve doctor-patient communication? (Longitudinal Curriculum)
  • Is there a cure for corporate crime in the drug industry? (BMJ Editorial)
  • Patient respect drops when doctors diagnose with computer.
  • Is Physician “Shadowing” a Shady Practice? 
  • Changes to ssisted suicide in Canada (15 minute interview with @PicardonHealth on recent legislation).
• Why Not to Get a Urine Drug Screen (except for altered mental status with truly no known explanation, unexplained new seizures, and if looking for cocaine):
  • Academic Life in EM (Peeing into the Wind Part 1, and Part 2)
  • MDAware’s take here
  • And a literature review forwarded by PharmERToxGuy
• Hemostasis
  • Acute Management of Bleeding in Patients on Novel Oral Anticoagulants (European Heart Journal. Subscription required, haven’t read it yet – caveat emptor).
  • Blood transfusions can be harmful or deadly in some GI bleeds (commentary by PulmCCM.org on this recent NEJM article)
• Resuscitwitter
  •  Decoding twitter: Surveillance and Trends for Cardiac Arrest and Resuscitation (Resuscitation. Subscription required).
• Advanced Illness/End of LIfe
  • ePrognosis – Check it out.  (thanks, Graham Walker!)
• #EMTOT
  • Not quite a trick of the trade, but something to know nonetheless – Perimortem C-Section, by Simon Carley at St. Emlyn’s.

And a moment of Zen from Professor Amal Mattu, as quoted by Prof. Joe Lex:

When troponin was a lousy assay, it was a great test. Now that it's a great assay, it's a lousy test – Amal Mattu #AAEM13 #FOAMed—
Joe Lex (@JoeLex5) February 11, 2013

Blog Page Updates: NEW! CONFERENCES SECTION

As a follow up on my recent Note to Conference Organizers, I’ve added a new page with a listing of upcoming conferences on EM, CC, Med-Ed, Bioethics, and Social Media in Medicine.  Check it out here.  You’ll notice general meeting info as well as a listing of each conference’s online presence including hashtags, when available.

The page will be constantly updated.  Its primary goal is to facilitate FOAM and off-site (maybe even on-site?) conference participation.   Please let me know when you have new additions or comments, or if I’ve excluded any good conferences in the current listing.

Also, the FOAM page has been updated to make it a little easier to read…

A Note to Conference Organizers Everywhere

Social Media, FOAM… Call it what you will, it’s pretty amazing.

Over the last few months I attended a bunch of conferences without having to pack a single bag.  In fact, I was able to keep up with regular ED shifts and continue with my “normal” life as an Emergency/Internal Medicine resident all while experiencing the 2012 Scientific Assembly of the American College of Emergency Physicians (ACEP), the 2012 meeting of the American Society for Bioethics and Humanities (ASBH), and the 2012 “Essentials of Emergency Medicine”.  These meetings took place in Denver, Washington DC, and Las Vegas, yet I had only to pick up my iPhone once or twice a day to keep up with all the latest updates and controversies coming out of these fora.

My impressions from ACEP and ASBH, based primarily on conference hashtags, can be found in the following posts: “Freeloading ACEP12“, “Virtually There“, “Lively Day at ACEP12“, “Final Counts…ACEP12“, “Peds Addendum“, and “ASBH From Afar“.  Thanks to the many active participants in both meetings I was able to create a daily narrative for each.  Reflecting on these meetings, and on my experiences live-tweeting from other national and local gatherings, including “iReporting” from SAEM 2012, got me to thinking…

Is the medical conference dead?

Dr. Tim Leeuwenburg at KI Docs had this to say in a post from October 29, 2012. He makes a very good point that: “…perhaps recent exposure to high-quality asynchronous #FOAMed learning has raised my expectations.”  He had, in fact, already learned much of what came out of the meeting he attended by utilizing the myriad of resources available via FOAM so what use is the conference?  My own experience has been the same.  By following Twitter, blogs, podcasts and vodcasts I find that by the time I get to the conference, the speakers are mostly rehashing what has already been discussed online.

Dr. Leeuwenburg quotes the never-ending wisdom of EM/CC educator and bard Dr. Joe Lex:

“If you want to know how we practiced medicine 5 years ago – read a textbook
If you want to know how we practiced medicine 2 years ago – read a journal
If you want to know how we practice medicine now – go to a (good) conference
If you want to know how we will practice medicine in the future – use FOAM”

Conferences used to be a place to hear the leading voices in our fields and to be exposed to the vanguard of our profession.  In an era of instant messaging and nonstop communication they are simply too unwieldy.  This role has been unceremoniously taken out of their hands.

Wait, Rewind

Didactics and innovation are not the sole purposes of medical conferences.  We also go to meetings for the human piece, the meeting of the minds.  Shmoozing, networking, campaigning – call it what you will, people like to get together and talk. They use this time to come up with new ideas, explore projects, find new collaborators.  Conferences also provide hands on, physical, access to equipment and practical workshops in ways that simply cannot be done (yet) in a virtual world.  Finally, the problem of quality assurance in FOAM remains unresolved (as addressed here on Academic Life in EM; and, here at IVLine and here at BoringEM).  Yes, FOAM can show us where the practice is headed, but it has a serious “buyer beware” attached.  For all you know I could be a 13 year old with good language skills and a pathologic personality.

So the medical conference must rethink itself.  While didactics are essential, once FOAM straightens out the kinks it will supersede conferences for straight-up learning.  The added value in traveling to a conference value comes out of physical human interaction and, of course, from being at the venue itself.

What To Do?

• Avoid traditional lectures to large groups, with exceptions for those particularly gifted speakers and thinkers who are able to effectively convey knowledge, and whom everyone simply “must” hear.  In most cases there other, more effective fora should be used.
• For large group sessions make use of panel discussions with innovators/thought leaders.  These provide for distribution of knowledge while allowing participants a peek into the cognitive processes driving changes in clinical practice.
• Maximize the use of hands-on practical sessions.
• Focus on simulation for procedural and general skills training.
• Embrace Social Media and FOAM.  Conferences are sometimes money making endeavors, and if not, they at least rely on registration fees and sponsor support to offset costs so “free” is often left out of the equation.  That said, the cost of attendance is a significant barrier to many trainees and physicians.  As free resources improve, the impact of conferences will decline unless they step into the world of Free Open Access Meducation (FOAM).  By doing so they will cement their role in the new order of medical education.  Online buzz preceding meetings could actually increase registration, and speakers, organizations, and sponsors will be able to reach a much broader audience.  Virtual meeting attendance (i.e. via social media resources) could increase conference reach and impact by orders of magnitude.  It might even be leveraged for financial gain by linking to paid resources, organizational membership, merchandise sales, etc. (sorry FOAM colleagues, got to make a business case here too).

Making Conference FOAM Happen:

Consider any and all of the following for a conference of any size.  Weekly local conferences, regional meetings, committee meetings, national assemblies, whatever.  They all can be enhanced through the tools of FOAM. 

1. Primary Hashtag - Decide on a catchy, intuitive term with minimal character use (5-6 characters seems to be the norm).  Hashtags are essentially keywords used to quickly locate a themed content on Twitter (other social media sites use the same concept).  Typically, the tag is preceded by a “#” (pound sign).  For example, the SAEM 2012 hashtag was #SAEM12.  Entering #SAEM12 in the Twitter search box would bring up all conference related posts organized by time.  Some hashtag uses: a) Conference promotion/PR, b) Backchannel communication (live, and around the clock conversation on conference topics), c) Speaker Q&A (and also allows participants to ask questions live without standing in those arduous microphone lines), d) Off-site participation (by following a hashtag and adding it to their tweets people can follow conference sessions from afar and contribute to backchannel discussion.  They can learn, submit questions and supplemental information, and participate in other constructive ways), e) Dissemination of information to the general public, f) Participation in multiple conference sessions simultaneously (by being in one room and following tweets from another), g) Marketing (unfortunately, hashtags are sometimes used for direct to physician marketing by conference sponsors and other commercial interest).
2. Sub-hashtags – Twitter feeds from very large meetings with thousands of participants and multiple parallel sessions can easily resemble the ramblings of a deranged mind.  With multiple people tweeting from simultaneous sessions it is sometimes hard to keep track of who said what.  Talk abut flight of ideas.  Also, the deluge of tweets from particularly popular sessions can easily drown out smaller concurrent sessions.  Consider, for large conferences, using sub-hashtags to identify tracks or particularly popular sessions.  This way users can filter out extraneous information and focus only the session they are following.  Of course, space is at a premium in the 140 character twitterverse, but adding even one letter to the primary hashtag can help.  For example, #ASBHa (for sessions in Track A) and #ASBHb (for sessions in track B) to allow for two parallel speakers and twitter feeds.  Other solutions would be to use specific identifiers, such as a session number, room number/name, or speaker name.
3. Register the hashtag – Sites such as Symplur and Twubs allow you to register hashtags.  Both have free and paid options.  Symplur specifically aims its services at the medical world.  Registration has a few potential uses, including staking your claim on the hashtag and listing it in a searchable database with a link to conference information.  It is unclear if registration provides any real benefit.  However, Symplur will also provide metrics so anyone can see who the most active hashtag users are, how many tweets have been posted, how many users they’ve reached, rates of retweets, etc.  A sort of real-time impact factor.
4. Encourage participation and include hashtags in PR materials - Picking a short and witty hashtag isn’t enough, people need to use it.  Get the word out by deciding on a hashtag early and including it in all promotional materials.  Not only will this help participants during the event, early adopters will also create a buzz long before the first session.  During the meeting, post hashtags prominently.  Consider asking speakers to incorporate them into their presentations, and remind participants to use them in their posts, blogs and other communications.
5. Twitterwall –  Reach those who aren’t on Twitter (or whose batteries have died) by installing twitterwalls in central locations (registration, lobby, etc) and on-stage during sessions.  There are two primary goals here.  First, LCD screens or projections in central locations allow everyone to see what’s going on in real time.  Lobby loungers or cafe chatters can see what sessions they’re missing and run to the rooms to get there in time.  Secondly, live twitter feeds presented on a second screen during sessions facilitate Q&A and allow speakers, and those not on Twitter, to keep tabs on the backchannel.  Some speakers will also embed tweets into their presentations (see next item, below).  Modalities range from a straight listing of all tweets in sequence (as might be used in a live session) to attractive animations of individual tweets as they come up (visually pleasing way of watching tweets in central locations).  There’s always a risk of inappropriate tweets showing up in public spaces, so some services offer a time delay or moderating function.  Examples include: Tweetwallpro, Tweetwall, Twijector, VisibleTweets, WallofSilver, TwitterWall, and many more…
6. Embedding twitter into presentations – Presenters may start incorporating tweets into their presentations.  For a variety of resources and uses, see this post by Timo Elliott on “Presentation 2.0“, Twitter Powerpoint and Twitter Prezi tools.  Some, not all, of these tools are free, but Twitter always is (for now).
7. iReporters – Assign specific people to “livetweet” sessions and call attention to special events.  This assures a constant flow of information and provides for some quality control.  Also, depending on how many followers an iReporter has, their posts can seed further discussion and conference buzz.  The conference hashtag ends up being associated with the brand, and organizers benefit from a well written feed.
8. Google+ Hangouts – Hangouts are essentially a video conference with up to 10 different users.  Google+ also offers a streaming mode, “Hangout on Air”, that automatically saves sessions to an associated Youtube account.  This tool might be used to informally Q&A with speakers or moderators, stream sessions live, facilitate discussions and committee meetings, etc.
9. Vodcasts/Podcasts – Develop complementary and summary podcasts to facilitate learning and discussion, and to drum up attention to the conferences.  Post these materials to the conference website and associated blogs.
10. Learn from other conferences – SMACC - The Social Media and Critical Conference that will take place in Sydney this March is testing the limits on this stuff.  Aside from incorporating some of the ideas listed above, they have also pushed user participation and user driven conference content to the extreme via PK-SMACC Talks and SMACC-Club.  Please follow the preceding links to learn more.
11. Create a Dynamic Online Presence – Most conferences already have some kind of a website.  A standard web page is a fantastic place to post static information, supplemental resources, speaker bios, whatever.  Consider adding to this a blog, Facebook page, Twitter account, Google+ page or community.  Just be sure to keep updating whatever channels you use.  An out of date or inactive blog, Facebook page or Twitter account is a huge turnoff.

I don't understand conf facilities charging for WiFi. I'll promote them if I can tweet more w/ tablet using WiFi. Hint hint @MarriottRVA—
Chuck Gates (@RVAChuck) February 01, 2013

Yes, all of the above assumes that participants have access to the internet.  Hopefully,  potential registrants will generally be able to use the internet before they come.  The real problem arises when lecture halls and convention centers lie under a monstrous hotel in cellphone dead zones, and then facilities try to take conference organizers or participants for all they’ve got just to pay for WiFi service.

It doesn’t make much sense.  But just as some hotels and airports are beginning to loosen up access to WiFi services – realizing the significant marginal profit to be had around internet use (after all, the internet itself isn’t the commodity, it’s everything else that exists online) – so I hope, conference centers will come to the realization that they are losing out with their current approach.

Be the Switchboard

Medical education is, slowly, being liberated by free online resources.  Thanks to its inherent flexibility, versatility, and pluralism, FOAM has already become the epicenter of cutting edge medical care.  It is clear that the medical conference is too slow to teach us “how we will practice medicine in the future”.  As web resources continue to increase in scope and reliability it will probably not be good at teaching us “how we practice medicine now” for much longer either.

But don’t give up on your frequent flier miles just yet.  Many physicians still rely on regional and national meetings to learn about new equipment or techniques and to undergo advanced skills training.   Furthermore, conferences remain an excellent venue to showcase research and to form new connections.  But the fact remains that conference conversations and even conference content have, like medical education, been jailbroken.  They are instantaneously conveyed to every corner of the earth on tides of FOAM.

For the medical conference to remain a vital part of the Med-Ed ecosystem it must build on its strengths while immersing itself in the new learning environment.  Organizers should capitalize on human interaction by focusing on high yield, small group sessions with content experts, and on practical workshops and directed networking sessions.  Large fora should be limited to a few particularly inspiring beacons of wisdom conveying not only content but also cognition; how do the masters think?  Most importantly, organizers must integrate a coherent FOAM strategy into the conference experience itself.  They are no longer there just to deliver information.  Conferences are now entering the realm of managing the live flow of data in and out of meeting halls, to and from the global medical conversation.

Don’t drown in the FOAM.  Love it, embrace it, flow with it.

Coalition to Transform Advanced Care Summit – Impressions

CTAC held its National Summit on Advanced Illness Care on Jan. 29-30 at the National Academy of Sciences.  The summit name in and of itself doesn’t say much, but the twitterfeed piqued my interest.  CTAC2013 focused primarily on ways to improve the quality of care we provide towards the end of life.  To visit their website, click on the logo (above) and for more info on the summit see their website here.

As has become habit, I followed the tweets coming out of CTAC very closely and have storified some interesting ones here.  This meeting seemed to be well attended and had a strong twitter presence.

Some themes:

• The need to reframe the discussion, merging curative and palliative care into a continuum
• Systems inherently obstruct palliative care, not necessarily by design
• Goals of care and advanced care planning as part of “regular” health care
• Linkage with employer benefits? (session with Goodyear physician)
• Evidence behind end of life and palliative care practices (EBM)
• Chaplains in palliative care

One more thing, this upcoming meeting at the IOM looks to be very interesting:

IOM cmte on Transforming End-of-Life Care will hold first meeting Feb. 20. Register for public session ow.ly/hg6j3 #CTAC2013—
InstituteofMedicine (@theIOM) January 30, 2013

Wink Wednesday #005

Logging new and noteworthy linkage from the endless Twitter feed, and other ephemera of the past week:

• Med-Ed and Doctoring
  • Is the Most Trusted Doctor in America Doing More Harm Than Good? (A profile from The New Yorker)  - read first.
  • Dr. Oz and Mr. Hyde: What Medicine Should Learn From Mehmet (Commentary in Forbes on previous piece from New Yorker) – read second.
  • We finally learn why Australia is so central to FOAM (video).
  • Food for thought on telemedicine in primary care.
  • Dr. Ryan Radecki on tPA policy shenanigans.
• Critical Care
  • Emcrit on Treatment of Aortic Dissection (posted Jan. 23)
  • It must be dissection season, because the very next day, on Jan 24, Keeweedoc posted this on spots and dogs with a link to some old FOAM Gold from LITFL: Die Like a King.
  • A week later, by some whim of fate, a colleague of mine covered the exact same topic in our weekly conference (slides unavailable, sorry).
  • And as a corollary to last week’s link to the NEW Surviving Sepsis Campaign Guidelines, here is Emcrit’s podcast on said guidelines, with commentary and pearls.
• #EMTOT
  • How to collect a baby’s urine on demand (by ImpactedNurse)
• Oh, the humanity!
  • A blast from the FFFF past with some critical care art courtesy Dr. Michelle Johnston

Wink Wednesday #004

Back to logging new/noteworthy linkage from the endless Twitter feed and other ephemera of the past – several – weeks:

• Med-Ed and Doctoring
  • Dr. Chris Nickson on FOAM love (6 min. video)
  • 6 Tips for the Flipped Classroom
  • 10 Tips for the many, many new features on Prezi
  • Samuel Shem, the author of The House of God, 34 years later with 4 new “laws” for good doctors (Atlantic Monthly).
  • Asynchronous learning in EM and also The Socratic Method (both from Academic Life in EM)
• Trauma/Coagulopathy
  • Impacted Nurse on Tranexamic Acid (incl. dosing, compatibility, addt’l references)
• Sepsis
  • The NEW Surviving Sepsis Campaign Guidelines
• Hypertension in the ED – a fantastic review by Lauren Westafer
• Primary Care
  • Should you go for your annual physical? (NYT)

 

NODESAT – Make It Happen

If you believe apneic oxygenation increases safe apnea time during intubation, and accept the NODESAT methodology, you’ve probably found yourself in an RSI conundrum.

Three devices are needed to  effectively preoxgyenate and safely intubate a patient: 1) O2 Mask (NRB), 2) Nasal Cannula (NC), and 3) BVM.  But with a maximum of two oxygen outlets in a typical hospital or transport berth it’s impossible to supply all three at once.  You might already be doing some version of the following if you have two connections:

1. During preoxygenation, place the mask and NC (+/- nasal trumpet/s) on the patient, both at maximum FiO2.  After 3 minutes of O2 Sat > 95%, or 8 vital capacity (maximal inhalation-exhalation) breaths, medicate.
2. Once apnea kicks in remove the mask, disconnect it from the wall, and hook up the BVM at maximum flow (leaving the NC on and running).
3. Proceed with laryngoscopy, etc.

The problem: In the mess of lines filling the narrow space above a patient’s head tangled tubing confuses assistants, stuff drops to the ground, etc…  As a result, RSI is no longer “rapid”, nasal cannulae get disconnected, and patients can end up off of oxygen for some time.

Getting out of the mess: Make Step 2 smoother and safer by taping together the ends of the mask and BVM oxygen lines while you’re setting up (photo above).  Plug in the NC and NRB (taped to BVM line) to two separate connections.  Once sedative and paralytic kick-in, simply ask an assistant to switch between the two taped lines (on right, below) as you’re removing the mask from the patient’s face.  This way, the lines are clearly marked, there is no need to touch the NC, and nasal oxygen supply to the patient continues uninterrupted.

Bonus point: Tape the lines in advance, while both devices are mostly in their packaging (though you may need to discard them at some point, check local rules). For safety mark the BVM line with tape and the letters “BVM”.

References:
1) Weingart, S., Levitan, R. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. Volume 59, Issue 3 , Pages 165-175.e1, March 2012. <;;a href=”http://www.annemergmed.com/article/S0196-0644(11)01667-2/fulltext
2) Levitan, R. NO DESAT! Emergency Physicians Monthly. December 2010.
3) Herbert, M. Apneic Oxygenation. EM:RAP
4) Apneic Oxygenation – for further reading see citations in Ref #1 (above)