Seeking help for mental health problems: Change the culture for providers

“I don’t need meds,” the young psychology major told me confidently. “Or therapy really. Maybe I’ll just touch base with you every once in a while. I should be able to handle this on my own.” The young woman’s physician had been concerned enough in a recent visit about this patient’s panic attacks and passive […]

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What I learned about childproofing from working in the ER

As a new mother, working in an emergency department made me want to go home and childproof every nook and cranny of our house. On a daily basis at work I care for children, most often toddlers, injured at home in various ways. I learned of all the potential household dangers and how to keep […]

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The human physician will soon become history. Here’s why.

In the age of spiritual machines Ray Kurzweil in 2001 predicted: By 2020, a $1,000 computer will match processing speed of the human brain — 20 billion calculations per second. By 2030, it will simulate the brain power of a small village about 1,000 human minds. By 2048, it will have the brain power of the entire population of the U.S. I predict that within 20 to 30 years the computer will replace the venerable physician. Computers can already be programmed to detect sarcasm and read emotions. They can study your face and body language. […]

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Much of the human spirit lies outside a physician’s power

I first met Marie five years ago. A petite, soft-spoken woman in her thirties, she was the patient of one of the residents whom I supervise at our community hospital. Marie worked in housekeeping for a large corporation; she and her husband, a bus driver, had a six-year-old son. Now she was twenty-six weeks (six […]

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3 things Walter White can teach doctors

Breaking Bad has been rated one of the best TV shows of all time, and for good reason. The improbable story of a regular and shy high school chemistry teacher, faced with a terminal diagnosis, turning into a gangster and drug kingpin certainly makes for good television. A compelling storyline set against the backdrop of […]

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It is time for an honest conversation about money and cancer

There are two, old, particularly nasty rumors, about cash and cancer. The first, which seems to be fading, is that scientists cured the disease long ago, but the pharmaceutical industry suppresses the cure so they can get rich selling worthless therapies. This never made sense to me, since the company or person that cures cancer […]

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When patient-centered care becomes patient-dictated care

“I’d like an MRI for my leg pain. I haven’t had an MRI for many years, and I’m worried.” These were some of the first words I heard from a patient I was seeing for a new patient visit. Based on this patient’s story and physical exam, her pain was most consistent with a muscle […]

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How good of a clinician are you?

In psychology, the Lake Wobegon effect refers to a mythical town where “all the women are strong, all the men are good-looking, and all the children are above average.” In other words, humans have a tendency to overestimate their capabilities, particularly in relation to others. As a physician, I have yet to meet a fellow […]

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4 things on the horizon in childhood cancer

The 20th century saw striking advances in curing childhood cancer, primarily as a result of the discovery that broadly toxic chemotherapy agents could kill malignant cells. As a result, pediatric cancer, once a virtually incurable disease, now enjoys an overall long-term survival rate that tops 80 percent. In the 21st century, attention is turning to newer […]

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Pain tolerance: A story of two patients

One thing I learned early on as a doctor is different people have different tolerances for pain.  At one end of the spectrum, for example, I recall a woman who came to the emergency department with a small splinter in her foot.  She arrived wailing in pain, and we had to take her back to […]

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Innovation in health care: Too much, too little, or just right?

I was recently discussing all the changes going on in healthcare at a summer cookout with a few doctors in private practice.  The topic of accountable care organizations (ACOs) came up, and the group started debating the pros and cons of them.  At one point in the conversation, I brought up Medicare’s Innovation Center (the […]

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LITFL Review 198

Welcome to the 198th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

A great new #FOAMcc website is born: ICM Case Summaries! This is what it is all about: “Writing ten expanded case summaries is a requirement of the CCT in Intensive Care Medicine training program for doctors in the UK. These summaries are usually the result of hours of work collecting, synthesising and distilling the most up-to-date evidence on specific clinical questions relevant to intensive care practice in the UK. For most of us though, once they are completed they just sit on our hard drives gathering e-dust. Our aim is to release the untapped potential of these resources and create an online repository of ICM expanded case summaries. As ICM Case Summaries grows it will form a continuously expanding and updating free online educational resource for intensive care medicine professional”. This is an excellent initiative that I hope all UK-based trainees and ICU consultants consider contributing to. The collection of posts is growing rapidly… One to watch! [CN]

The Best of #FOAMed Emergency Medicine

• Excellent review of the evidence behind the use of nitrates and NIPPV in decompensated heart failure in the ED from HEFT EM Cast. Includes the disutility of loop diurectics. [AS]
• More great podcasts coming at a quick-fire rate from CORE EM. This time it’s the management of DKA. [SL]
• The All NYC EM Podcast features Pik Mukherji discussing heuristics and diagnostic errors. [AS]
• Rebecca Maxwell from the Severn FOAMed Network delivers a fantastic podcast on Tricyclic Antidepressant Overdose and discusses the role of intralipid. [SL]
• EM Lit of Note discusses new targets for finding patients amenable to catheter-directed therapy in ischemic CVA for reperfusing at-risk (as opposed to infarcted) tissue. [AS]
• An interesting update on The Alteplase Controversy Goes Prime Time, as the concern over stroke thrombolysis gains more momentum. [SL]
• The Bottom Line reviews an excellent RDCT comparing low dose ketamine to morphine for acute pain management in the ED. [AS]
• Mistakes in medicine are inevitable but rarely gets discussed. This fantastic blog from Sweat the Small Stuff talks about medical errors in a open, honest and informative manner. It is essential reading for all. [SL]
• The latest episode of ERCast delves into the difficulty of deciding “is my patient suicidal”? [MG]

The Best of #FOAMcc Critical Care

• Video demonstration of the core micro-skills necessary for expert central line placement from EM Crit. [AS]
• There has been a surge in case-based Q&As over at INTENSIVE, courtesy of Chris Sia: congenital heart disease in an adult is the focus of Cyanosis, Boots and the 5Ts, key finds on AXR in Belly ache and Rigler’s Sign, and the differential diagnosis of different types of lung opacitites on CXR in Why the alveolar opacities?. [CN]
• Deirdre Murphy (aka ‘ECMO Goddess’!) talks to San Diego’s finest podcasters Joe and Zack about Weaning VA ECMO on the EDECMO.org podcast. The discussion provides great insights into the management and weaning of VA ECMO patients in the ICU. I could have done with hearing this a few years ago! [CN]
• Cardio-pulmonary physiology maven Jon-Emile Kenny has made his Critical Care Medicine board exam review notes available on PulmCCM.org. [CN]
• ScanCrit reviews the recent article in Annals of Surgery looking at the utility of FAST in predicting patients who will not benefit from ED thoracotomy after trauma. [AS]

The Best of #FOAMtox Toxicology

• ECMO makes a double mention this week at the Poison Review: ECMO as a bridge to lung transplantation in paraquat poisoning and ECMO in colchicine poisoning [JAR]
• How does obesity affect the poisoned patient? The Poison Review discusses a recent article on the topic. [AS]

The Best of #FOAMped Paediatrics

• New free iBook – Pediatric Emergency Medicine Guidelines. [AS]

The Best of Medical Education and Social Media

• Excellent podcast discussing how we can reconcile novel education (i.e. FOAM) with the traditional models at Injectable Orange featuring Vic Brazil and Damian Roland. [AS]
• If you’ve got a presentation to give soon then this is a must listen! Jonathan Downham talks to Ross Fisher on how to make a fantastic presentation. [SL]

News from the Fast Lane

• There are now over 1,600 entries in the Critical Care Compendium… and counting! [CN]

Reference Sources and Reading List

• Emergency Medicine and Critical Care blog/podcast list
• LITFL Global Blogroll
• FOAMEM RSS feed syndication for global FOAM
• Twitter: #FOAMed – #FOAMcc – #FOAMtox – #FOAMped – #FOAMus – #FOAMim

Brought to you by:

• Anand Swaminathan [AS] (EM Lyceum, iTeachEM)
• Brent Thoma [BT] (BoringEM and Academic Life in EM)
• Chris Connolly [CC]
• Chris Nickson [CN] ( iTeachEM, RAGE, INTENSIVE and SMACC)
• Joe-Anthony Rotella [JAR]
• Kane Guthrie [KG]
• Mat Goebel [MG]
• Segun Olusanya [SO] (JICSCast)
• Simon Laing [SL] (HEFTEMCast)
• Tessa Davis [TRD] (Don’t Forget The Bubbles)
• Marjorie Lazoff [ML]

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Why doctors and digital experts should work together to improve patient health

As a family doctor, I have seen a dramatic shift in the range of people I work alongside every day — all for the better. When I was in training, most family doctors worked only with other family doctors and registered nurses. Today my health care team is rich with a variety of critical skills, […]

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I despise my EHR. But I’m still using it.

Modern electronic health records (EHRs) have become the norm in U.S. health care — nearly 80 percent of office-based physicians use them, up from 40 percent in 2009, according to federal data. But while adoption is up, satisfaction has plummeted. In 2010, about 61 percent of physicians liked their EHRs (were satisfied or very satisfied, according […]

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The story of the pot-smoking neurosurgeon is more complicated than you think

A brief article recently posted the name and picture of a neurosurgery resident accused of smoking marijuana on the job.  Dr. Gunjan Goel, MD is a neurosurgery resident at University of California, San Diego, and the list of her awards and publications alone is almost as long as my entire CV.  The article is brief, […]

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Doctors should beware the attribution sign. Here’s why.

When getting a medical history, patient attribution can be very helpful.  We are even taught in medical school to specifically ask patients what they attribute their symptoms to.  For example: Doctor: “What do you think is causing this pain in the right upper part of your abdomen?” Patient: “It happens every time I eat a […]

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How a head CT changed everything for this patient

From her vantage point, cost had nothing to do with money. On most days, she struggled to her feet when I entered the room, greeted me effusively, and escorted me to her bedside chair, all the while chattering about the inadequacy of our hospital’s slushies, the beauty of the day outside, and the latest update […]

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Are physicians really to blame for the opioid addiction epidemic?

During my training in the 70s, heroin use dominated our substance abuse horizon.  We saw many patients with IV drug-related complications.  We saw heroin overdoses. For the next 30+ years, we rarely heard about heroin.  Over the past 10 years we have seen increasing opiate abuse, but the opiates came from prescriptions.  Over the past […]

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Test your medicine knowledge: 33-year-old woman with atrial fibrillation

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 33-year-old woman is evaluated as an outpatient following an episode of atrial fibrillation. The episode resolved shortly after she arrived at the emergency department. She has a history of tetralogy of Fallot with repair performed at the age of 4 […]

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The human cost of breast cancer screening

Karen Vogt’s breast cancer journey began like many others, with her breasts painfully squeezed into a mammography machine. At age 52, it was far from her first mammogram, but this scan would be the most consequential by far. It revealed microcalcifications, little areas of breast tissue speckled with deposits of calcium that her radiologist worried […]

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Why it’s important for physicians to talk about bias

I’m not racist. I would never refuse to give a patient pain medication or fail to properly get her on a transplant waiting list just because she was black. And, yet, to deny that I hold any bias would be foolish, naïve at best. Ask any American if he or she is racist, and you’re […]

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Who is caring for the caregivers? A medical scribe’s perspective.

I’m not going to be a doctor. It feels more like a confession than a statement — like I’m disappointing someone. Each time I say, or even think, those words, I feel as if I need to atone for it. Survey a hundred scribes.  Ask them of their goal in becoming a scribe, and all […]

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Sometimes the best care a patient can get is a discussion

Dear attending, I’m a third-year medical student fresh out of the classroom.  I’ve studied from books for years, and now I finally get to see what it is like to be a doctor. It’s exciting but also a daunting experience. I look to you as a guide: what you wear, how you speak, what tools […]

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Funtabulously Frivolous Friday Five 117

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia…introducing Funtabulously Frivolous Friday Five 117

Question 1

You have a patient with the Thinker’s Sign (or Dahl’s sign), what condition is your patient likely to have?

+ Reveal the Funtabulous Answer

• Thigh hyperpigmentation
• This sign was described in 1963.
• Hyperpigmentation on the thighs is caused by repeated pressure from sitting in a tripod position (similar to Rodin’s Thinker).
• Most patients suffer from COPD [Reference]

Question 2

This is a Curschmann’s spiral – with what condition is it commonly associated?

+ Reveal the Funtabulous Answer

• Asthma
• Spiralled mucous plugs containing shed epithelium
• Most often seen in the sputum of asthmatics (but can also be in several lung diseases). [Reference]

Question 3

What was known as the “Vietnamese time bomb“?

+ Reveal the Funtabulous Answer

• Infection with Burholderia pseudomallei
• Vietnam war veterans often developed this, up to a decade after returning from Vietnam.
• It is hypothesised the helicopter blades would spin the bacteria into the air as the soldiers were embarking or disembarking.
• B.pseudomallei is a slow growing bacteria and presenting with a broad spectrum of symptoms from dermal rashes to liver abscess. Mortality can be as high as 40%. [Reference]

Question 4

While at the gym, a patient in her 30’s suffers an episode of visual loss, but is relatively undistressed by it. What condition may she suffer from and name the phenomenon?

+ Reveal the Funtabulous Answer

• Uhthoff’s phenomenon
• This episode may be an exacerbation of multiple sclerosis
• MS symptoms exacerbated by heat and exercise (e.g. exercise increasing body temp) is known as Uhthoff’s phenomenon. [Reference]

Question 5

We have all been involved with the palliative care of a patient at some point, but what are the origins of the word ‘palliative‘ and when did hospices first come into existence?

+ Reveal the Funtabulous Answer

• The term is derived from the Latin word palliare – which means “to cloak“.
• The first hospices (in the current/”medical” sense) were established in 1967, although hospice-like facilities have existed since the fourteenth century. [Reference]

…and in other news

//www.youtube.com/watch?v=fypm_aeR5qA

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Caring for the dying patient is a rewarding challenge

I walked silently into the pristinely decorated room of the hospice facility and was greeted by her family.  She lay there, not particularly responsive to her surroundings under the pressure and influences of metastatic stomach cancer.  The warmness and smiles on the faces of her family told me that at some point and somehow, in […]

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The first step to combat the nation’s obesity epidemic

“I’m doing my part. I want to get better and go home,” Dorothy says as she looks up at me from the hospital bed. We talk about her family and work life, and she tears up several times during the conversation especially when she talks about how her mother died of cancer. “I’m afraid to […]

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A letter from an educator to medical trainees

Dear trainee, I was once in your shoes. There was a time where I wore a beat up white coat, pockets overflowing with cards and knew every nook and cranny of the hospital. I was the doctor that woke up the patients in the am, gently asking them to roll over so I could listen […]

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The time to reinvent medicine is now. #TakeBackMedicine

For too long we have let politicians, insurance companies, lawyers, administrators, and consultants tell us what is best for our patients. Over the years, we’ve stood idly by and watched as the field we love is debased, one superfluous policy after another — foolishly believing that if we just worked a little bit harder, we […]

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TechTool Talk 005 with James Edwards

As part of TechTool Thursday, I thought it would be interesting to look at more than just app reviews.  This week I interview James Edwards

James Edwards is an Emergency Physician at Royal Prince Alfred Hospital. He has recently set up a new website for junior doctors called onthewards (onthewards.org).

Tell me a bit about your medical background/career?

I am an Emergency Physician and Deputy Director at Royal Prince Alfred Hospital Emergency Department. I was the Director of Prevocational Education and Training for 6 years until taking up the Chair of NSW Prevocational Training Council within the Health and Education Training Institute (HETI) last year

What led to you starting onthewards?

In a discussion with Jeremy Faust at SMACC on the Gold Coast he mentioned the need to find a niche in the rapidly expanding FOAM resources. I recognised a gap for prevocational junior doctors in Australia.

Where did you learn your IT skills?

I didn’t. I’ve learned to delegate to others with more IT knowledge and skills.

What is the aim of onthewards?

To develop FOAM education resources for generalist junior doctors. The podcasts and blogs acknowledge the transitional phase of internship, and supplement the vast experiential learning that occurs.

Didn’t you find trying to get onthewards up and running within the hospital system to be a bureaucratic nightmare?

We run onthewards in parallel with the hospital system. Medical administration can see the attraction of improving engagement with junior doctors, but we maintain independence from the hospital system whilst acknowledging their support in providing resources to produce the podcasts

What has been the key to your success developing onthewards so far?

Supporting passionate individuals to contribute ideas and content to the website – the recognition that a website for junior doctors has to be driven by junior doctors.

What are your aims for onthewards for the next couple of years?

Updating the website and developing an onthewards app for mobile devices.

Continuing to collaborate more widely outside our hospital.

Encouraging more FOAM websites aimed at junior doctors.

Is onthewards FOAM and are you aiming to keep it that way?

We want the website to be free, independent and openly accessible to all junior doctors. But acknowledge that “free” sometimes comes with a cost and are considering carefully our next step

What or who inspires you?

The passion, enthusiasm and engagement of junior doctors that I have worked with.

What is the best piece of advice you have been given?

If in doubt, do what is best for the patient.

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Research and Reviews in the Fastlane 100

Welcome to the 100th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Palliative Care, Critical Care

Kelley AS, Morrison RS. Palliative Care for the Seriously Ill. NEJM 2015; 373:747-755. PMID: 26287850

• This excellent review article emphasizes palliative care being interdisciplinary care involving multiple specialities e.g. medicine, nursing, social work, chaplaincy, etc which focuses on improving quality of life for persons of any age who are living with any serious illness and for their families. Core components of palliative care include the assessment and treatment of physical and psychological symptoms, identification of and support for spiritual distress, expert communication to establish goals of care and assist with complex medical decision making, and coordination of care. Excellent cognitive road maps for Breaking Bad News such as SPIKES (setting up the interview, assessing the patient’s perception, obtaining the patient’s invitation, giving knowledge and information, responding to emotion, and summarizing the discussion), and others to express empathy with the use of NURSE (naming, understanding, respecting, supporting, and exploring) are described and could be utilised in our practise.
• Recommended by: Nudrat Rashid

The Best of the Rest

Immunology, Infectious diseases
Gaeta F et al. Tolerability of aztreonam and carbapenems in patients with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol. 2015;135(4):972-6. PMID: 25457154

• True penicillin allergy can potentially limit antibiotic options as many antibiotics from cephalosporins to carbapenems to aztreonam have reported cross-reactivity. A number of publications have shown low cross-reactivity (1-3%) between penicillins and cephalosporins as well as low cross-reactivity between penicillins and imipenem/meropenem (~ 1%). This study, using skin tests, found that 0 out of 211 patients demonstrated cross-reactivity between penicillin and aztreonam. The authors recommend skin testing prior to administration and skin testing isn’t a perfect surrogate for a systemic reaction upon IV administration but the best evidence we have shows that cross-reactivity is highly unlikely.
• Recommended by: Anand Swaminathan

Pediatrics

Park G et al. Randomized single-blinded clinical trial on effects of nursery songs for infants and young children’s anxiety before and during head computed tomography. Am J Emerg Med. 2015. PMID: 26314215

• This RCT randomized children aged <4 years who were undergoing CT scans to receive either nursery rhymes (via musical CD) or standard care (with no music). The children who received the music had significantly lower agitation scores measured using a visual analogue scale (absolute difference 2.4 cm, p=0.03). The paper has some weaknesses. For example, even though the research associate assessing agitation wore earphones to block out any music, they seem unlikely to have been truly blinded to allocation because they’ll have seen the child’s reaction. What’s more, the difference is modest. Still, it’s a nice idea and gives us some evidence (even if it does have weaknesses) to suggest that music might be helpful in this situation.
• Recommended by: Rick Body

Emergency Medicine

Un, et al. Novel Vagal Maneuver Technique for Termination of Supraventricular Tachycardias. AJEM 2015 PMID: 26209466

• A brief case series that describes the success of a new vagal maneuver for termination of SVT in the emergency setting. Basically, the authors describe moving patients quickly from a sitting to a supine position, and their success with 5 different patients. This is certainly a benign enough procedure without significant foreseeable harm, so well worth attempting before placing an IV and pushing adenosine. Another arrow in the quiver!
• Recommended by: Jeremy Fried

Critical care

Kosova E, Bergmark B, Piazza G. Fat embolism syndrome. Circulation 2015;131(3):317-20. PMID: 25601951

• Although a review, this article highlights a rare, but important and often misdiagnose entity: Fat Embolism Syndrome (FES). FES is defined as the presence of fat globules in pulmonary circulation. Common affected population are young (10-40) patients with long bong trauma but it can be seen in pathological fractures or bone marrow disease. The pathophysiology is thought to be related to a mechanical obstruction plus a sever inflammatory process (similar to amniotic fluid emboli). Classic presentation is respiratory failure, neurological abnormalities and petechiae. Diagnosis is challenging and based on clinical presentation, isolation of fat particles in wedge circulation appears not to be of great help for the diagnosis, the authors recommend the use of Gurd criteria (http://bit.ly/1umarLp). Treatment consists in general aggressive intensive care support.
• Recommended by: Daniel Cabrera

Systems and Administration

Asch DA, Rosin R. Innovation as Discipline, Not Fad. NEJM 2015; 373(7):592-594. PMID: 26267619

• Most of us have a bunch of ideas that we think might make our hospital work better.Most of us do not implement those ideas.This is because full implementation would take a bunch of money or resources to build a whole system. So we are stuck unable to implement a fix because we cannot get the resources; unable to get the resources because we do not have evidence it will work; and unable to get the evidence it will work because we cannot implement the fix.Asch and Rosin provide a set of ingenious solutions for breaking out of this bind. They describe a set of strategies stolen from the technology industry but that they are implementing in healthcare. (Rosin used to work for Quicken, of tax accounting fame.)Pertinently, they provide pragmatic strategies for being able to develop a test-able fix without making most of the investment needed to make a permanent fix. If the test-able fix works, one has evidence to command the resources to make in permanent. If it does not, no harm done, one can move on quickly to a new test-able fix.Particularly for people early in their careers—or in resource-poor environments—these strategies seem enormously useful. The article prompted a bunch of ideas for me, anyway. The bottom line: don’t wait until everything can be done perfectly; find the critical part of a potential solution, find a way that might be good enough to make it better, objectively evaluate it in a real situation, and learn from the result.
• Recommended by: Jack Iwashyna

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of famer You simply MUST READ this!		R&R Hot stuff! Everyone’s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R Mona Lisa Brilliant writing or explanation
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

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The top 10 mistakes premedical students make

We all go through it. We all have regrets in life. They simply become painful, unescapable daydreams of “what could have been” if only I had only … I often remind young college freshmen who have finally gotten a taste of freedom stepping out of their parent’s home, that what they choose to do in […]

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Can you teach the art of medicine?

When I first applied for medical school, I beamed about exploring not just the science of medicine, but also the art.  But what is that art?  Some would say it’s clinical experience, combined with being cultured and compassionate and communicating with clarity/conviction.  But how would one teach that art? Journal Watch’s Dr. Allan Brett recently reviewed a multicenter […]

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The problems with patient feedback forms and how to fix them

We’ve all seen them: those once paper but increasingly digital forms that enthusiastically request our feedback. “Tell us how we’re doing,” they cheerfully announce, or, “Help us improve!” Some of us even send them out as part of our practices or health systems or educational programs. We also fill them out, both as regular citizens […]

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#NursesUnite against The View. It’s time to set the record straight.

Kelley Johnson’s monologue from the 2016 Miss America competition was poignant and powerful. The hosts at The View chose to mock it instead.  It’s time to set the record straight. Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.

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Patients are taking far too many medications. It’s time to fix that.

Medication non-adherence is a hot button topic in health care. Physicians lament patient “non-compliance” with their medical advice, and policy wonks tell us that more than half of patients do not take their medications as directed. Missed opportunities to control chronic illnesses such as diabetes, heart disease, and cancer surely do cost us untold billions […]

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After a drug overdose: Is it malpractice or murder?

Is a doctor guilty of malpractice or murder or is the patient responsible for his or her actions when there is a death by overdose? This is the question that a jury in Los Angeles will have to decide as they are presented the facts in the case of Dr. Lisa Tseng. The prosecution’s version […]

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The tragedy of opioid addiction in the young and homeless

Katie had always come to clinic in an anxious and frazzled state. Hair blond hair disheveled, large handbag open, items at the verge of spilling out. Yet she came, dutifully, to meet her counselor, to attend group therapy, to get vitals checked by her nurse, then to drop off a urine sample. But not today. […]

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You can’t tell whether a psychotherapist is impaired

Two of the most commented posts on my blog are about charging patients for missed sessions and how psychotherapies end.  As there is no single correct approach to either of these, there’s plenty of room for practices legitimately to vary, and plenty of room for patients, i.e., most of my commenters, to express their likes and dislikes.  By my […]

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Why we are #ProudtobeGIM: A general internal medicine top 10 list

A strong wind would have knocked Geraldine to the ground. At 78 pounds, she was underweight, chronically ill, and in need of acute medical or psychosocial care every time she came to the clinic. A survivor of domestic violence with severe mental illness, she had a history of substance abuse and was infected with both […]

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What to say when medical certainty is elusive

Doctors do not know everything. We make mistakes and mistakes in judgment. Sometimes we make the mistake of speaking when we should keep silent. At times, patients ask us questions that we can’t or shouldn’t answer; and yet we do. It shouldn’t be our objective to force certainly into an issue that is amorphous and […]

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Medicine can still be noble. If we fight for it.

It occurred to me towards the end of our conversation that there was a large gaping hole.  We had talked about physician burnout, career choices, and his current plans.  He had drawn a map of his future.   It originally shot like a straight arrow towards clinical medicine, but now veered precipitously.  I took a […]

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Treating cancer: Doing nothing is also a choice

Dear doctor: Attached please find the medical records of Mr. Ron C., who is transferring medical care to your office. Ron is a 63-year-old gentleman with recurrent lung cancer, which has spread to his opposite lung and bones. There are multiple treatment choices for his disease, which we have discussed in detail. However, Ron is […]

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The cafeteria can tell you a lot about the hospital. Here’s how.

Hospital cafeterias are important places. Great progress has been made over the last few years in raising the standard of the food served (to both patients and staff!), with much more emphasis too on making the options healthier and nutritious. Speaking as someone who has worked in several different hospitals, and with my own general […]

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Less regulation in health care. Please.

Pharmaceutical drugs cost too much. The new ones are always so expensive. Hence, we need more regulations. And, the government should impose them. Set price limits. Cap drugmaker profits. This will make it better for all of us. The paternalism of our government should be the strongest when we are ill. Because we may need that medicine. […]

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Can you fake empathy until it becomes real?

Studies show over and over again that empathy is the key to physician-patient communication and is directly related to patient satisfaction, adherence to medical treatment, lawsuits, and clinical outcomes. Yet despite its importance, many doctors still struggle with showing empathy. The reality is that while most medical students start school with high levels of empathy, […]

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LITFL Review 197

Welcome to the 197th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Want to hear a specific article critically appraised? Submit your picks to The SGEM using their superb Hot or Not process, a fantastic new FOAMed feature. [SL]

A superb new resource collating intensive care case series, with evidenced-based answers to really useful clinical questions: icmcasesummaries.com. [SL]

The Best of #FOAMed Emergency Medicine

• Dr. Smith’s ECG Blog discusses the short differential diagnosis list for a large R wave in V1. [AS]

The Best of #FOAMcc Critical Care

• Anton Helman welcomes Rich Levitan, Andy Sloas and David Barbic to discuss the management of the critically ill obese patient. [AS]
• Chris Hicks discusses the 10 Commandments of Trauma Resusc on REBEL EM. [AS]

The Best of #FOAMus Ultrasound

• The US of the Week blog highlights a case of necrotizing fasciitis rapidly identified by POCUS. [AS]

The Best of #FOAMtox Toxicology

• Core EM reviews hyperinsulinemia-euglycemia therapy in the treatment of calcium channel blocker overdose. [AS]
• If you missed last week’s News from the Fast Lane: the LITFL team has developed the Toxicology Library! Check it all out here. [ML]

The Best of #FOAMped Paediatrics

• Don’t Forget the Bubbles has teamed up with APLS to release the videos from the 2013 and 2014 Paediatric Acute Care Conference, online and freely available; after this year’s conference in October, the videos from 2015 are promised to appear online as well. Their first video is Gary Williams on Emerging Viral Infections. [TRD]

The Best of #FOAMim Internal Medicine

• As the folks at Louisville Lectures are still on summer break, you have time to catch up on  the specialty list of Grand Rounds-type lectures online posted over the past year.  [ML]

The Best of Medical Education and Social Media

• The Skeptics Guide to EM (SGEM) goes global with new podcasts in French, Spanish and Portugese. [AS]

News from the Fast Lane

• There are now over 1,600 entries in the Critical Care Compendium… and counting! [CN]

Reference Sources and Reading List

• Emergency Medicine and Critical Care blog/podcast list
• LITFL Global Blogroll
• FOAMEM RSS feed syndication for global FOAM
• Twitter: #FOAMed – #FOAMcc – #FOAMtox – #FOAMped – #FOAMus – #FOAMim

Brought to you by:

• Anand Swaminathan [AS] (EM Lyceum, iTeachEM)
• Brent Thoma [BT] (BoringEM and Academic Life in EM)
• Chris Connolly [CC]
• Chris Nickson [CN] ( iTeachEM, RAGE, INTENSIVE and SMACC)
• Joe-Anthony Rotella [JAR]
• Kane Guthrie [KG]
• Mat Goebel [MG]
• Segun Olusanya [SO] (JICSCast)
• Simon Laing [SL] (HEFTEMCast)
• Tessa Davis [TRD] (Don’t Forget The Bubbles)
• Marjorie Lazoff [ML]

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All actors should have to take a CPR class

The doctor sprinted to the side of the bed and slapped her interlaced hands over the man’s heart.  What made his heart stop remained a mystery, but she knew she had to get it beating again. She pushed her hands into his chest, an internal metronome pacing her efforts. After every few pumps, she glanced […]

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How anatomy lab changed this medical student forever

I’m supposed to speak at the body donor memorial in September. I told the organizers my speech was written. “Don’t worry,” I assured them. “I have it all in my head, just need to get it down on paper. I’m a writer; it’s my process.” But the truth is that I am struggling with what […]

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The day I saw the humanity in medicine

At the heart of American medicine is the concept of bedside manner, and with it the concern that doctors are cold and unemotional. Indeed, doctors are exposed to disease and misfortune on a daily basis. A patient who presents with stage IV metastatic stomach cancer is just one of the many hundreds or thousands of […]

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Now is the time for acute pain medicine specialists

A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com. Since September is Pain Awareness Month, it’s time to recognize that not all pain is equal. Chronic pain can be alleviated, but “acute” pain (sudden onset, brief in duration, often with an identifiable cause) must be eliminated. This requires a systems-based approach led by physicians dedicated to […]

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3 ways to improve your delivery of bad news to patients

On July 3, 2015, at approximately 2:00 a.m., I was awakened by my mobile phone ringing.  I looked at the number the call was originating from and was fearful this was the call I was dreading to receive.  My mother’s long-term care facility was calling, and the news was not good.  My mother was found […]

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Let’s remove the uncertainty hospitalized patients endure

Medicine has undoubtedly come a long way. Paternalism has been ditched in favor of a shared decision making approach, diagnoses and treatments are (largely) based on scientific evidence, and information is not outright withheld from patients out of some misplaced belief that they are not capable of handling the truth. Some of the modern pain […]

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Test your medicine knowledge: 22-year-old man with diarrhea and weight loss

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 22-year-old man is evaluated for diarrhea and weight loss. The patient has a 3-week history of foul-smelling, large-volume, watery stools associated with abdominal bloating. There is no visible blood or mucus in the stools. He reports a 4.5-kg (10-lb) weight […]

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Medicine can suck the compassion out of you. But I still give it my best shot.

Compassion. Once upon a time, I had a lot of it. I guess I still do, or I wouldn’t be at this desk. I think most medical students start out that way. We want to help the sick, heal the wounded, decrease suffering. All that stuff we once wrote in the “personal statement” section of […]

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Academic medicine still discriminates against women. Here’s one story.

My idealism has been stolen. No other way to express how I feel just days past my third anniversary from graduating from fellowship. Post college, I spent thirteen additional years in training to become the specialist physician I am. I am reminded now of my Facebook post stating I was about to start my first […]

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I wish HIPAA had privacy settings

“There’s such an issue of privacy in health care, and yet they let all the patients walk around with their derrières sticking out.” This quote within an article by the National Post got me thinking about HIPAA. The Health Insurance Portability and Accountability Act of 1996 is a big flat hammer with excellent intentions. Like EMTALA, […]

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6 reasons why doctors grieve differently

I’ve been thinking about this over the last ten and a half years since my soul mate had a cardiac arrest and died. He was 38 and as fit as a fiddle. I am a rural general practitioner in South Australia (family practitioner in American parlance). He left behind four kids (from his previous relationship), […]

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Funtabulously Frivolous Friday Five 116

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia…introducing Funtabulously Frivolous Friday Five 116

Question 1

What was the cause of Derbyshire neck?

+ Reveal the Funtabulous Answer

• Iodine deficiency
• Thyroid goitre due to iodine deficiency. [Reference]
• In the 18th Century, doctors were baffled by a mysterious condition that affected many of the people of Derbyshire. The afflicted, were mostly women and suffered a swelling on the bottom of their throats.
• “It generally occupies the whole front of the neck,” said local scholar Thomas Prosser, “as the whole thyroid gland is here generally enlarged, but is rather in a pendulous form, not unlike the flap or dew-cap of a turkey cock’s neck.”

 

Question 2

Who famously took a lethal dose of strychnine followed by a charcoal chaser in front of the French Academy in 1831 and survived?

+ Reveal the Funtabulous Answer

• Professor Touery
• In front of his distinguished colleagues at the French Academy of Medicine, Professor Touery ingested 15g of strychnine (a lethal dose) mixed with activated charcoal – and lived to tell the tale. [Reference]
• M. Bertrand (a French chemist) was the first to perform such a daring experiment on himself to demonstrate the effectiveness of charcoal to absorb poison. In 1813 he ingested a lethal dose of arsenic after mixing it with activated charcoal. He survived his experiment.

Question 3

What’s the best use for marmite?

+ Reveal the Funtabulous Answer

• …solving the Arab-Israeli conflict in the middle East
• At least according to Edward de Bono in advice he tendered to the foreign office in 2000.
• The logic, briefly, is this. Hypozincemia makes men irritable and belligerent. You get zinc in yeast, which is fine for your average loaf of bread. But in the Middle East, the bread is unleavened. Ergo, the great man says, Marmite is the answer to easing the way to peace. [Reference]

Question 4

What can you tell about a man from his shoe size?

+ Reveal the Funtabulous Answer

• They need big shoes
• According to a study in 2002 published in the British Journal of Urology International there is no link between the size of a mans penis and is shoe size.
• 104 subjects were thoroughly measured at two hospital sites in the UK and they found the average Caucasian penis to be 3.5 inches (8.9cm) long with no correlation to shoe size. [PMID 12230622]
• Additional information can be found…for the uber inquisitive in a study of nomogram charting penile length studies in 15,000 men [“Am I normal…” PMID 25487360]

Question 5

What is the stroop effect?

+ Reveal the Funtabulous Answer

• Demonstration of interference in the reaction time of a task
• Classically, naming the colour of the first set of words is easier and quicker than the second. The original paper is one of the most quoted in experimental physiology. It has been used in dementia, brain injury, ADHD patients and even on Everest to test attention capacity. [Reference]

 

…and in other news

//www.youtube.com/watch?v=I3f3pTbKmow

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A little girl stopped this physician from asking why

It is not uncommon for doctors to question the reasons why we do what we do.  The journey is long. The debts often seem insurmountable.  The harsh lessons learned from a mistake made with best of intentions are an unforgiving punishment for “life without forgiveness.” Memories may fade, but the scars always seem to linger. […]

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TechTool Thursday 064 Touch Surgery

TechTool review Touch Surgery on iOS and Android

The Touch Surgery app is unlike any app I’ve seen before. It simulates surgical procedures to allow teaching and testing of students and trainees. Touch Surgery has a huge team behind it who have created surgical simulation software. The procedures and operations contained in the app are authored by different surgeons from across the world.The aim is to develop a collaborative resource consisting of best surgical practice in order to share and learns with other health professionals

Website: – iTunes – Android – Website

Design

This app is a pleasure to use. Everything from the icon, the screen layout, the fonts, and colour schemes are just right. Navigation through the app is smooth and it did not crash on me at all. A model for how medical apps should look

User Interface

Touch Surgery Android

Touch Surgery iPad

Touch Surgery iPhone

Clinical Content

• The app contains over 50 surgical procedures.
• A couple are included when you install the app, others have to be downloaded.
• The modules cover a range of surgical specialties and include procedures from chest tube insertion to acute trauma craniotomy
• When you enter your area of interest, the app suggests videos that might interest you.
• Each module has ‘test’ and ‘learn’ options. The learn option shows you step-by-step how to complete a surgical procedures. After this, you can test your knowledge.
• All the modules use excellent graphics and gestures to allow the user to interactively learn.

Cost

• The app is completely free.
• I’m astounded that it is, as it would be reasonable to charge users $10 to purchase this. I assume that Touch Surgery makes money by licensing it out to institutions to use for teaching and for the development of new operations

Room for Improvement

• When setting up my free account I was only asked to enter my password once, and couldn’t see the password to check I had typed it correctly. This has the potential to result in frustrated users who are locked out of their accounts due to password typos.
• All of the modules took a long time to download – potentially this was due to my internet connection but I downloaded via a fast wifi connection.
• I struggled to find out how to open and start new modules – when it looked like they were finally downloaded, the button to start them was missing. Was my account restricted in some way? If so, the app should make this clear.
• Another module that appeared to be downloaded told me there was an error with module when I tried to start it.

Overall

In spite of the technical glitches I experienced, I love this app. The graphics and design are among the best I’ve seen and there a great team of experienced healthcare professionals and developers behind this.

I seemed to have a lot of bad luck when using this app, however. I suspect some of the restrictions were due to pending verification of my account, but if this was made clearer in the app then it would be less frustrating for users.

The modules that I was able to complete were really helpful from an anatomy point of view, and also will be handy if I ever decide on a career change. I now feel pretty confident that I could do a carpal tunnel release without any supervision, so maybe I’ll look at surgical training next.

//www.youtube.com/watch?v=UiWHXO5fAbA

//www.youtube.com/watch?v=_aULgS-jZ0Y

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I started singing in the procedure room. And it reshaped my view of professionalism.

In medical training, one of the main things that is emphasized is the importance of acting professionally. We encounter patients who have a particular idea of how doctors are supposed to act during the patient-physician encounter, and for the most part, I expected that they would want a doctor who is caring, but serious, at […]

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Is your hospital a miserable place to work? Here are 14 clues.

Earlier this month I read a Wall Street Journal article about Zeynep Ton’s Good Jobs Index. Who is Zeynep Ton? She is a professor at the Massachusetts Institute of Technology’s Sloan School of Management who has ranked retailers on employee happiness. This was so positive. It was good to hear about businesses concerned about employee happiness […]

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Informed consent defines 21st-century medicine

I walk into a tiny ER room and shut the glass door behind me. The smell is dizzying. I look down and see a frail man lying on a stretcher. A soiled bandage on his left leg is halfway unfurled. He is diaphoretic. He sleepily opens his eyes when I say his name. For me, […]

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Discussing the side effects of medications: How can doctors do better?

While studying for a certification exam, I came across a question that stayed with me well after taking the practice test. The case discussed a patient who was prescribed antibiotics by his physician for a presumed bacterial illness and then returned the following week with an antibiotic-associated diarrheal infection. The test question then asked what […]

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Research and Reviews in the Fastlane 099

Welcome to the 99th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Peri-operative Medicine, Cardiology

Douketis JD et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015; 373(9):823-833. PMID: 26095867

• This randomized, double-blind, placebo-controlled trial assigned patients with chronic (permanent or paroxysmal) atrial fibrillation or flutter who had received warfarin therapy for 3 months or longer, with an international normalized ratio (INR) therapeutic range of 2.0 to 3.0 and were undergoing an elective operation or other elective invasive procedure that required interruption of warfarin therapy; and had at least one of the CHADS₂ stroke risk factors to receiving bridging anticoagulation therapy with dalteparin sodium (100 IU per kilogram of body weight administered subcutaneously twice daily) or to receive no bridging therapy (i.e., a matching subcutaneous placebo) from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. The results showed that  for this group of patients a strategy of forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism. The strategy of forgoing bridging treatment also decreased the risk of major bleeding.
• Recommended by: Nudrat Rashid

The Best of the Rest

Emergency Medicine

Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin ‘‘allergy’’ in hospitalized patients: A cohort study. J Allergy Clin Immunol.  2014;133(3):790-6. PMID: 24188976

• Allergy to penicillin class drugs is extremely common. However, most studies show that only 1-5% of patients who claim an allergy actually have one. This article investigates the additional costs that occur as a result of penicillin ʺallergyʺ being placed on a chart. In this observational study, the authors found that patients had longer hospitalizations and at more risk for C.diff, MRSA and VRE infections. Overall, they found that it would be much cheaper and more efficient to test every patient to try and establish true allergy (or more likely, absence of allergy) than to continue to spend health care dollars in this way.
• Recommended by: Anand Swaminathan

Emergency Medicine

Murphy N et al. Gestation-specific D-dimer reference ranges: a cross-sectional study. Br J Obstet Gyn 2015; 122:(3)395-400. PMID: 24828148

• The workup of pregnant patients with possible pulmonary embolism is complicated because the beloved decision aids haven’t been validated for use in this population and we know d-dimer levels increase naturally during gestation. This study took a sample from healthy pregnant patients (n=760) at different stages of gestation. They found, unsurprisingly, that d-dimer increases with gestational age, congruent with limited prior literature. They propose a continuous increasing d-dimer in pregnancy. With PE experts such as Dr. Kline proposing gestation adjusted d-dimer, this is a research space to watch.
• Recommended by: Lauren Westafer

Systems and administration

Del Portal DA, et al. Impact of an Opioid Prescribing Guideline in the Acute Care Setting. J Emerg Med 2015. PMID: 26281819

• As many EDs implement voluntary opioid prescribing guidelines, this study is the first of it’s kind to examine outcomes after doing so. The prescription opioid abuse epidemic in the U.S. is a well known problem and a black eye on the face of medicine as it’s an issue we created in an attempt to alleviate the suffering of our patients. Unfortunately, the pendulum clearly swung too far to the side of liberal distribution and we are now dealing with the consequences of over prescribing. The authors in this study detail their experience implementing a voluntary guideline at multiple ED sites. They found that opioid prescriptions for dental, neck, back, or unspecified chronic pain decreased from 52.7% before the guideline to 29.8% immediately after its introduction, and to 33.8% at an interval of 12 to 18 months later. Additionally, 100% of ED faculty supported the guideline. Importantly, providers were able to ʺoverrideʺ the guideline at their discretion and a state prescription monitoring database was not available at the time of the study.
• Recommended by: Jeremy Fried

Ultrasound and imaging

Bouhemad B et al Ultrasound for ʺlung monitoringʺ of ventilated patients. Anesthesiology 2015; 122(2):437-47. PMID 25501898

• The use of lung ultrasound (LUS) is ever expanding. Today we know several specific LUS patterns corresponding to lung pathology and for some of these we have couple specific treatments. However the problem with LUS has mostly been how to communicate findings between clinicians and to monitor these over time. This paper offers a scoring system to monitor degree of lung aeration over time and as response to specific treatments, ie PEEP and prone position, in the ventilated patient.
• Recommended by: Søren Rudolph

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of famer You simply MUST READ this!		R&R Hot stuff! Everyone’s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R Mona Lisa Brilliant writing or explanation
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

 

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