Exploring the Spectrum of Burnout to Wellness

Just in time for #CAEPWellness2017 Mikayla presented at Grand Rounds on the topic of Burnout to Wellness.She presented a great deal of literature on the topic and made a convincing case for finding ways to help each other thrive.

My favourite part of the presentation was when she displayed word clouds made from our group’s responses to a quick survey she had sent ahead of time. The words below represent how our group manifests burnout.

Better yet was her forward-looking, optimistic look at how we might thrive! Mikayla highlighted some things our department already does and pointed to a couple of other institutions and online discussions on the topic including the ALiEM Journal Club “Thriving, Not surviving, in Residency“. This word cloud displays the strategies that our group uses to get and stay well.

At the end of the day as institutions, friends, colleagues, peers, and individuals we have the ability to support each other in being the best version of ourselves possible. At QEmerg we will continue to find ways, big and small, to navigate the spectrum of burnout to thriving.

Check out information about International Emergency Medicine Wellness Week with lots of available resources and important discussions here. Please add your favourite wellness hacks below!

Grand Rounds: don’t RUSH ortho

In this week’s edition of Grand Rounds Zack performed a quick review of the RUSH exam for undifferentiated shock and Theresa outlined some easy to miss orthopaedic injuries. Below are a few resources on both below! 

The RUSH Exam

In the patient with undifferentiated shock you can use the power of the ultrasound to evaluate the “Pump, Tank and Pipes” or the HI-MAP. See the EMCrit post from the original creators.

rush-exam

For a super primer on the RUSH/HI-MAP exam check out this video from 5 minute soon here or this post from ALiEM.

Happy scanning with our new high frequency probe!!!

Easy to Miss Ortho Injuries

There is far too much to cover from Theresa’s awesome review on this topic. I’ve decided to highlight a couple of the injuries that she mentioned with links to the resources about those injuries for some quick reading.

There is a spectrum of scapholunate injuries that are easy to miss. These range from scapholunate dissociation (widening of the scapholunate joint) to peri-lunate dislocation to lunate dislocation.

The posterior shoulder dislocation can be easy to miss. Keep your eye for the lightbulb sign. Maybe we can consider using ultrasound for catching the diagnosis?

The lateral elbow x-ray is your friend. Keep your eye out for signs of occult fracture in this view.

I really appreciated Theresa’s discussion of the Ottawa Ankle rule. She reminded us that these rules can help assess the need for imaging but the components do not make up a complete or thorough ankle exam. Remember to check the proximal fibular head and examine the whole ankle and foot.

Theresa’s 10 Commandments for Ortho Injuries

  1. Know what you are looking for
  2. Obtain proper, perpendicular views, multiple views and specific views
  3. Be aware of specific, occult and dislocation radiographic signs
  4. Know what “normal looks like”
  5. Avoid being distracted
  6. Develop a systematic approach to xrays
  7. Use cognitive forcing strategies – (i.e. always document snuffbox tenderness and DRUJ findings in wrist exams)
  8. ALWAYS obtain post reduction films
  9. Examine the joint above and below
  10. History and physical trump ALL. Examine, image, re-examine.

 

 

Grand Rounds: Stop the Bleeding!!!

Our awesome Stu Douglas did a fantastic job of bringing together the evidence, the lack of evidence, and evidence of the future together into a practical rounds on reversal strategies for anticoagulation and anti-platelet agents.

Consider using the StuDoug Approach (TM) when you see a patient who just won’t stop bleeding.

stop-the-bleeding-png

Download a copy of this click here!

If you are an emergency medicine, elective resident, medical student or otherwise rotating through our program in Kingston and would like to contribute to QEmerg.org please get in touch with Eve or Kristin at (epurdy at qmed.ca)!

Summer Series: the Art of Regional Anesthesia

This is the final summer series post for 2016! We ended the season with a great session on nerve blocks followed by an adventure to the Agnes Etherington Art Centre for a session on art appreciation.

Below is an infographic, created by Andrew Helt, that can act as a quick reminder of the types of nerve blocks that you can use. You can check out Vault Ultrasound or keep Joey’s sheet handy by taking a picture of it and adding it as a favourite on your phone for more in-depth reminders at the point of care.

regional-anesthesia regional-anesthesia

After learning about nerve blocks we headed across campus to Agnes Etherington. If you haven’t had the opportunity to check it out you should go! The curators were setting up new installations while we were there so it is sure to be enjoyable.  In case you are skeptical about this as a component of our academic curriculum, I will direct you to these resources discussing the value of humanities in medical education here, here and here.

The summer series was a great introduction (for some) and return (for others) to the foundations of emergency medicine. We are looking forward to the academic year ahead!

Summer Series: Central Lines and Trauma

In this week’s edition of the summer series we learned about central lines and trauma. Though these sessions were on the same day, don’t forget that the central line is not a resuscitative line…unless it’s a cordis.

Central Lines

In the morning Bruder and the senior residents introduced us to a number of different central lines and we had the chance to practice seeing the anatomy in real-time. Though one of our first year residents claimed the largest IJ in the crowd, I was pleasantly surprised at my ability to expand my IJ.

Central lines are really best learned in the sim laboratory and we are fortunate to have a curriculum in central line placement as second year residents. This session allowed for the sharing of some more practical tips and tricks, similar to these central-line tips and tricks from Haney Mallemat.

Trauma

In the afternoon Tim and Chris led us through high fidelity simulation of four difficult trauma cases. The lessons learned ranged from Simulationa discussion of cyanide toxicity (covered by Shar in a previous rounds here) to difficult airways to neuroprotective intubation. Towards the end of the day we were thirsty to learn more and one resident asked where we might learn more about trauma. We have compiled a list of some trauma learning resources.

Text books: Chris and Tim both recommended that textbooks are a great place to start to develop a framework for trauma management. Rosen’s/Tintanalli’s are a good start but there are a ton more in our resident library. Make sure to check them out.

Trauma Guidelines: The Eastern Association for the Surgery of Trauma provides comprehensive guidelines for the management of most trauma related injuries that you can access here. Unbeknownst to most of us, there is also a Western Trauma Association and publish a number of helpful algorithms. It seems these two groups might benefit from joining forces…

Journals: Keeping up to date on trauma literature means surveying the literature. The Journal of Trauma and Acute Care Surgery and Trauma are starting points.

Online Resources: Below are a number of websites that we have found helpful when reading about trauma. IVLine (for the very basics), The Crashing Patient (a rather comprehensive overview of everything trauma),  Life in the Fast Lane (a large number of trauma related posts), The Trauma Professional’s Blog (case discussions, pearls, tips and tricks).

Just in Time Resources: We learned in this session that everyone should have easy and ready access to a paediatric app such as pedistat or PalmEM to help mitigate the stress of medication doses and equipment size in paediatric trauma.

Please comment below if you have additional resources about learning about central lines or trauma! Look forward to seeing you for the next session!

Summer Series: Deliberate practice, airways, and chest tubes

Round two of the summer series was led by the dynamic duo of Bob McGraw and Carly Hagel. They spent the day teaching us a very deliberate approach to airway and they also employed an impressively engineered model to practice chest tube placement. Perhaps the most important lesson of the day, DON’T CLAMP THE CHEST TUBE.

The 7 P’s of Intubation

Dr. McGraw highlighted the importance of an unchanged routine in preparing for airway management to free up cognitive space. One thing we did not directly discuss but we might consider implementing into practice in our next intubations is a checklist to ensure that we have not forgotten any of the important equipment or mental steps.

We repeated our setup dozens of times throughout the morning with direct and immediate feedback. This deliberate practice is one step in the movement towards expertise. Here is a reminder infographic on the 7 P’s of intubation that we practiced on Thursday. For more information about how to “Own the Airway” check out these links on Life in the Fast Lane.

summer-series-airway

To download a pdf of this infographic click here.

As Dr. McGraw pointed out, positioning is an often overlooked, critical aspect of the successful intubation. Though an article from the anesthesia and critical care world, this is an interesting review of some (low quality) literature discussing Back Up, Head Up positioning for intubation in a population of high risk patients that may be similar to those we see in the ED. Food for thought at the least!

Chest Tubes

The pretty nifty simulated model for chest tube insertion was a great way to practice the technical skill, outlined by this NEJM article and videos. The skill was easy when compared to the discussion of how chest tubes work and how to trouble shoot when things go wrong. We got deep into a discussion respiratory physiology. There were many take aways but the main was:

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

Clamping the chest tube is one way to make the patient much worse. Clamping the tube can cause a tension pneumothorax, making a bad situation for the patient much, much worse. When you are trouble shooting, get back to the basics. Take a deep breath, slow down and remember the circuit, even draw it if you have to!

Please share any resources you have found helpful or comment on your approaches to deliberate practice, airways or chest tubes!

Summer Rounds: Ultimate Introduction to Ultrasound

The posts over the summer months are going to change in format! The structure of our academic program in the summer is such that we cover core topics and skills in emergency medicine in weekly, daylong sessions. We will either pick something interesting from the session to focus on or provide a look at some available online resources for each session.

Our first 2016 summer series session was an ultrasound extravaganza to give the newcomers to QEmerg a feel for ultrasound, the basic concepts and get them ready to start acquiring scans. It also gave those with some experience the chance to practice and teach as well! We covered the aorta scan, subxiphoid view, FAST and gyne scans. Thanks to Louise, Joey and Connor for putting on an awesome session with tons of hands on time! If you had fun on the day here are a few neat articles and resources you might want to check out.

  • SonoMojo provides an outlined curriculum of basic ultrasoScreen Shot 2016-07-08 at 10.56.15 AMund skills with links to podcasts and videos to brush up on the basics. I especially like their cheat sheets for a quick reminder.
  • One Minute Ultrasound is an app that provides quick
    reminders of key landmarks and techniques.
  • Matt and Mike’s ultrasound podcast is great or check out their awesome iBOOK “Introduction to Bedside Ultrasound”  complete with videos, it truly is an unreal learning tool.
  • Tons more FREE ultrasound resources are outlined on this LITFL blog post

Feel free to add your favourite ultrasound resources in the comments section below but don’t forget, none are a substitute for hands on probe time with teachers showing you the ropes! Happy scanning!

Journal Club: Qualitative Research and Double Sequential Defibrillation

In this week’s edition of journal club we covered a paper that, through qualitative methods, assessed emergency physicians’ thoughts on opiate guidelines. As a group we have been speaking a lot about opiates and so we have elected not to cover the article in-depth in this review. We spent most of the night discussing qualitative methods in general. Below are some take aways for the next time you pick up a qualitative paper!

A great resource for critical appraisal of qualitative research is this BMJ article.

Journal Club May 2016

To download a pdf version of this article click here.

The staff article this week was an article looking at double sequential defibrillation and you can access it here. Though a simple case series it provided quite enthusiastic discussion. Next time you run into Adam or Colin ask them about what they think!

Look forward to seeing you at the next Journal Club!

Grand Rounds: Medical Ethics

This week we were fortunate to have Dr. Mikayla Brenneis share her insights on medical ethics. Mikayla is currently completing a Masters in Ethics and brought nuanced perspective on a number of issues including ethical principles, the ethics of CPR and advance directives, and an overview of physician assisted death in Canada. The audience discussion was rich and I hope that it extends beyond the walls of Richardson. In particular, the importance of the “Code Status” discussion was highlighted. Proper training about how/when to have this conversation and the types of systems that might exist to better ensure a clear understanding of patients’ wishes were discussed and seemingly warrant more airtime.

The infographic below is a very cursory overview of some of the topics covered. I would encourage you to pick Mikayla’s brain the next time you see her. My understanding of ethics in daily practice have certainly expanded since she’s generously spent time sharing her expertise. In addition to checking out the infographic see the CPSO Statement on “Planning for and Providing Quality End-of-Life Care” and read the full text of Bill C-14.

grand-rounds-may-12 To download a PDF version of this infographic click here.

I’m looking forward to more discussions on these important topics and to seeing you at next week’s edition of Journal Club and Grand Rounds!

Grand Rounds: Rethinking M&M and Opioids

Grand Rounds

Dr. Stuart Douglas reminded us this week about the purpose of medical morbidity and mortality rounds. He presented a model “The Ottawa Model” to enhance the quality of discussions. This comprehensive guide suggests ideal ways to identify cases, analyze cases and promote movement towards improvement in system processes as a result. It may be worth reading before presenting at such a case conference. Throughout the presentation we discussed a number of biases and varieties of error that are a reality of practicing emergency medicine. This list of 50 Cognitive and Affective Biases compiled by Pat Croskerry may be helpful when considering contributing factors to specific cases and could be worth reflecting on every once in a while, even in the absence of identifiable adverse events or poor outcomes.

If you have time you can read “Monday Mornings” , Sanjay Gupta’s fictional account of surgical mortality and morbidity rounds. Probably more an example of how NOT to run M&M.

Kristen has highlighted in the infographic this week some of the features of morbidity and mortality rounds done right. Of note, the safe, no-blame culture that Stu deliberately created is key.

May 5, 2016 Grand Rounds

To download a pdf version of this infographic click here.

Staff Rounds

Screen Shot 2016-05-09 at 1.26.29 PM
source – drugstrategy.ca

This week Dr. Kieran Moore from public health led us through a look at the opioid epidemic. The increase in opioid related deaths since the early 2000s in Ontario is humbling and Frontenac county is a particularly high prescribing area.

Moral of the story: We are in the middle of an iatrogenic outbreak caused by over prescribing. Prescribing opioids, for non-cancer pain, in any significant quantities does more harm than good.

This website, StreetRx, shows in real-time the going street price for prescription drugs. Pretty scary to see the going price for narcotics coming from, in Kieran’s words,  “our pens”.

Dr. Moore has become a tireless advocate on this public health issue. You can check out some of his recent articles here.

Keep your eyes open for more from Kieran on this issue coming down the pipelines soon.