(Yet more) reflections on SMACC Gold

Lots of other folk have put their reflections on SMACC Gold online and I’m here to join the crowd.

I missed the first SMACC as purse strings were a little tight. They’re a little tight this year too but I really wasn’t going to miss two SMACCs…

It was great to have an opportunity to come and speak though I’ll confess I was much more comfortable teaching neuroanatomy than being on the airway panel with Levitan, Weingart, John Hinds and Brent May. But it was all good really.

levitan 1

I was very impressed that they chose to devote a 2 hr main area session on end of life issues that incorporated a live integrated twitter discussion.

SonoWars in particular caught my eye as one of the most creative and slickly ran sessions on education I’ve ever seen. Those guys (ultrasoundpod and the sonocave guys) are the best in the business.

The highlight though, without doubt, was the people. This is why you come to SMACC, to meet and be inspired by people. You can throw this off as soft and fluffy and no relevance to medicine but this was the key thing.

smacc gold audience

Ireland has a small EM community and it’s a tough place to do EM. We have a very small number of trained EPs and our departments are crowded, understaffed and morale is frankly pretty low at times. It’s hardly surprising that so many of our trainees or EPs have moved to Oz or New Zealand.

As a result #FOAMed has been an inspiration and an revelation to me. To know the imaginative possibilities of EM out there is what gets me excited about the job. I get to discuss online with some fascinating, interesting and passionate clinicians from whom I can learn. SMACC gold gave me the chance to meet these people in person. And meeting people in person beats twitter hands down.

People who engage in #FOAMed tend to be a little bit off the spectrum in terms of our enthusiasm. We love the medicine, we love to talk about  medicine and we just can’t get enough of talking about medicine so much so that our spouses, our friends and even our medical colleagues get bored of us. SMACC is a conference for all these enthusiastic, excitable little puppies to get together and bond with all the other freaks and geeks.

All these people, the passion, the enthusiasm and the relationships are an inspiration to be a better doctor and a better team member.

So my thanks for SMACC gold are to the people. In particular the committee for being mad enough to invite me and Rob Rogers for being a great roomie – that man rocks!

Here’s some more reflections on SMACC gold so you can check out the love.

I Teach EM

Manu Et Corde

REBEL EM

Injectable Orange

LITFL

Jess

KI Docs

Doug Lynch (with a fascinating set of interview)

Damian Roland

AmboFOAM

Nomadic GP

Bishan

[Let me know if I missed any]

And here’s the opening ceremony

We’ll be in Chicago next year in May 2015 and I for one plan on being there. Be sure and check out the SMACC podcast to catch up on all the talks.

[Images via Oli Flower]

Severn Deanery 2014 Social Media Workshop

This is the post I created for the guys who attended the Social Media workshop at the Severn Deanery meeting in January 2014. It is based loosely on material from the Irish EMS gathering that I took part in last year Hopefully something from the 2 hrs stuck in your brains so that you’re not seeing all this as entirely new material. Hopefully I’ve included all the services and apps mentioned during the workshops.

Remember that there are lots of useful links and all the audio from the day over at the Severn Deanery Website. Kudos to Tom Mitchell for that.

For more info on the day itself check out the EMJ Blog that has an article outlining the day.

Twitter

Firstly we got everyone to join Twitter. Or at least we tried to until the Hotel wifi started playing silly buggers. There was some kind provision of personal hotspots that enabled access.  You access twitter via the website or via an app on your computer or phone. For interest sake I use  TweetDeck  through  Chrome on my computer and use Twittelator Pro on my iPhone. There are lots of different apps available that allow you to access twitter so feel free to experiment a little.

I suggested that when you join twitter you should put a little of biographical information about yourself. People are more likely to interact with you if they know something about you. There are a lot of fake, spam Twitter accounts and having some info on someone helps people to trust you. I think it’s worth describing whether you’re a trainee or a fully trained physician on here too.

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

Twitter EGG

For example here’s mine:Andy Neill Twitter Profile

Follow People 

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

@sandnsurf

@precordialthump

@cliffreid

@broomedocs

@M_Lin

@EMManchester

and of course everyone’s favourite, Cliff, the college president

@CEMpresident

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

Follow Lists

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

Here’s a list I have of “medical tweeters

And here’s the list of all the tweeters from the conference.

Follow Hashtags

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

Of note there is also a #FOAMcc stream for more critical care topics and #FOAMped stream for kiddies. Or rather it’s about paeds EM, it’s not really for kids to read…. that would be just silly.

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

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

Podcasts

I think the key is to get your podcasts on your smartphone. That way wherever you are yo can listen to them. It’s much more important to have them on your phone your computer in that sense. I suggest turing off podcast sync between itunes on your computer and your phone. You’ll only really use them on your phone anyhow.

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

podcast 1

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

podcast 2

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

podcast 3

 

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

podcast 4

LITFL have a great list of podcasts and a searchable database too, if you need to find more. The Severn 2014 Website has a pretty good list too.

Feed Reader

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

feedly

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

RSS

 

or copying and pasting the website URL into the search box

feedly search

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

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

Blogs

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

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

wordpress

This is all free and easy to do via wordpress. I would strongly encourage you to get a wordpress account and fiddle around with it.

Google Plus

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

 

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

Google plus does the cool thing of recording these video calls for you and storing them as a (private) YouTube video that you can then post on whatever website you want.

There is also the rather nifty community feature on google plus that can function in the same way as the #FOAMed hashtag but allows much more substantial conversation and response rather than the 140 characters of twitter. Here’s two examples

1) FOAMcc

2) ECG+

Screencasts

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

Screenr.com let you record screencasts without having to download a separate app but I do a fair bit of this so I use one called screenflow. If you have a mac you can do this very easily by using quicktime on your mac. It comes free bundled with the operating software.

To do this:

1) Open QuickTime Player

QuickTIme

2) Start a new screen recording [File>New Screen Recording]

New Screen Recording

3) Choose Mic and Quality

Choose Mic

4) Make your screen selection or if recording a screen presentation, just start recording full screen then make your presentation full screen

Choose what you want to record

At the end just press stop (there’ll be a stop symbol at the top of your screen) and then you’ll have a nice little video file of your screencast. Upload this to YouTube, put the link on Twitter and Robert is indeed your Mother’s Brother.

As an example here’s a screencast of a talk similar to the one I gave at the severn conference. The audio from the Severn Conference is available here.

[If anyone wants the slides for the talk they're available as a keynote presentation.]

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

SMACC Gold is Coming

I missed last years SMACC, much to my dismay. A much awaited baby and a struggling bank account got in the way. The baby was (and still is fun), the bank account not so much…

But SMACC is back. It’s not just some guys in the back of a pub talking about twitter as Scott remarked. While it still may be a tad testicle heavy, the line up for SMACC Gold (it’s in the Gold Coast in Oz, hence the name…) is looking pretty great.

I’ll be there and even have the pleasure of getting to give a little talk. On anatomy of course…

The registrations open Monday and the big thing to look out for are the pre-conference workshops –  there’s some pretty cool ones but they’ll be sure to sell out fast so get in quick.

According to my screenshot below Cliff Reid’s forehead will be there and two, count ‘em two Matt Dawsons.

See you all there.

SMACC GOLD Featured

The decision to intubate – the follow up

[Image Wikipedia Commons]

A few days ago I posted a few cases to try and elicit the reasoning behind why we intubate people. Check out the comments to get a feel for what people were saying. Here’s some follow up. Though first a bit of preamble on context.

For the US readers, it takes a lot to get into an ICU over here. Most of our non-invasive ventilation and DKA patients and lots of other folk that you might send to the ‘ICU’ go to a ward here. From what I read/listen to, there are a lot more patients going to ICUs in the US, and a lot less sick patients in the ICU.

For starters, intubation is of course just one part of the care. It’s all well and good intubating an obtunded leaking AAA but it kind of misses the point. Intubating someone, while a vital part of management, is rarely going to fix the problem in isolation. Intubation, however, does tend to set in motion a whole series of clinical procedures and (if they remain intubated) dictates disposition to an ICU setting.

Secondly, there are some genuine and major issues surrounding bed availability in most of the UK/Ireland. Critical care beds are at a premium and it’s very common to have intubated patients in the ED for prolonged periods (by which I mean overnight, rather than the 2 or 3 days that I heard can happen in the US) and often having to be transferred to other hospitals where a bed is available. Just as a full ED is bad for patients, a full ICU is going to be bad for patients and those patients trying to get in.

Just like in an overcrowded ICU, there are rarely the nursing staff or medical staff to look after the ongoing needs of a ventilated patient in the ED for prolonged periods and this is of course, by no means ideal.

Decisions about intubation (which implies that we think they need ongoing critical care – remember that might change when we find out they’ve had a massive, non-survivable ICH) are influenced by all kinds of ‘non-clinical’ needs like these. Registrar to registrar referrals at 4am are different from 10am referrals when all the bosses are around. In the rather dysfunctional, ‘sickest looked after by the thickest’  model (UK/Ireland) where trainees continue to provide the vast majority of care there are a lot of pragmatic decisions made that perhaps would be made differently if the only people involved were consultants at 10am following a nice latte and a ward round on a half-empty ICU. You may disagree with that, but I think that’s the honest view of things.

In my experience decisions regarding intubation and ICU admission (and indeed most major decision in medicine) are frequently different when there are consultant level staff involved, on both sides – ED and ICU. Let me put it this way, the outcome (eg intubation or ICU admission) might be the same but the process to reach that decision will be somewhat different (usually quicker and more convincing) when the people deciding it are on a higher pay grade than me.

A remarkably good job is done in this non-ideal situation and it is rare that anyone actually comes to harm from it. But it is frankly naive to think that we all (as trainees or consultants) make wonderful, unbiased purely clinical decisions all of the time.

So… in this resource limited, pretty screwed up situation that I find myself, the decision to intubate is a fairly major one. In my current dept, we seem to have a good relationship with ICU and they seem more supportive than usual of the ED performing RSIs. Having said that, my threshold for intubating someone is still pretty high.

I don’t know what you all did with the 3 cases I presented but I have managed 3 very similar cases, all without intubation.

Case 1 

This person has what Weingart calls SCAPE. (creepily Dave Menzies used the exact same phrasing in his comment…) This is acute pulmonary oedema. With NIV and massive doses of nitrates it is rare for me to need to intubate someone like this. They look much sicker than lots of other patients that you might intubate and the nurses will stare at you in shock when you say you don’t want to intubate them.

Neither GCS, pH, resp rate, even hypoxia tip your hand to intubate these people. In another condition then of course you would intubate them if they were this sick but the big difference is that this is easily (well relatively easily) reversible, and rapidly reversible without intubation.

Most of the ones I’ve seen present at 5am (why?) and you can frequently have them drinking tea by 9am if you play your cards right.

Case 2

this person has fairly significant cocaine toxicity. If he seized then I’d intubate him but otherwise what this man needs is neither ventilation nor airway protection but massive doses of benzos. I’m yet to break 200mg of diazepam yet but I’ve got close. If he got too sedated, then of course, he may need an advanced airway but most of the time you can get away with it.

A lot of people mentioned that he’ll have renal failure but CK doesn’t seem to predict full blown AKI that well that I’m aware of. With teenage kidneys, good fluid resus and a catheter I’m not sure he’ll need dialysis.

In general I’ve found that these guys don’t get floored with sedation. I stand at the bedside cracking open amps of diazepam, doubling the dose each time until the diaphoresis stops. Hardly the most scientific of end point but a ‘conscious sedation’ level comes about the same time as the sweating stops, then I let them sleep it off. Treat till they’re dry?

Case 3

this is the tricky one I think. 8 times out of 10 this chap is just seizing from missed meds and too much booze. But of course he could well have a big bleed in there causing it. The decision to CT him is easy. The decision to intubate him isn’t as clear cut. The key thing that isn’t mentioned in the vignette is treatment. This man may be in status but he has not yet had any treatment. If he seizes after reasonable doses of benzos and phenytoin then yes he gets a tube. If there are genuine airway concerns (as opposed to simply “GCS less than 8 concerns”) then he gets a tube too.

Some final thoughts

It is, of course, perfectly reasonable to intubate all 3 of these patients. Lots of you would and it would be hard to disagree. And, of course, just cause you might ‘get away with it’ by not intubating them, doesn’t mean that you’ve done a good job – I don’t think we need a specificity of 100% for intubation, it’s likely more important that our sensitivity for intubation is on the high end. Airway protection is often cited as reason to intubate but whether or not the airway is safe or not can only be determined in retrospect – did they obstruct or aspirate – if they didn’t then you could argue they never needed the airway protected in the first place.

Perhaps the only thing I’m trying to illustrate here is that the decision to intubate is a tricky one. Bottom line, when you’re with the patient in resus it’s often your call (depending on whether you need to outsource your airway management/ICU admission to someone else.)

Someone may disagree with you, sometimes for good reasons, sometimes for shitty ones. The techniques of making things happen that Cliff teaches so well, are quite simply vital to the care of your patient when you’re coming up against some less than pristine clinical decision making on the other end of the phone. You won’t always need it though – there are plenty of patients where my initial inclination has been to intubate but with the presence and discussion with ICU team, there’s been a collaborative decision to manage without intubation.

This is just scratching the surface of a really deep and complex question. To think that it all boils down to a decision to put plastic in the trachea is a little bit simplistic so help me out in the comments with what else you think makes the decision to intubate.

PS The general trend in your responses for intubation was:

1) No

2) Yes though some wouldn’t

3) Yes

 

The decision to intubate

[Image Wikipedia Commons]

[This has been floating about as a draft post here for ages, but Cliff has finally inspired me to put it out there and have the discussion following his recent post on The tongue-in-cheek non-intubation check list]

This is one of the trickiest decisions in EM in my opinion. Now for lots of patients it’s really easy: the severe sepsis with white out pneumonia or the severe head injury.

However, lots of people fall somewhere in between. In the past 6 months I’ve treated a number of patients where the decision could have gone either way. For example, here’s some theoretical cases. I’ll let you work out the (hopefully) obvious diagnoses.

Case 1

72 male presents via ambulance at 0500 having woken from sleep with shortness of breath.

He is clearly unwell with a systolic BP of 180, HR of 180 a horribly broad LBBB ECG with a rate of 110. He is diaphoretic, agitated but responsive to voice with sats of 70 on oxygen. His RR is 30 and the chest is wet like an Irish summer. GCS is single figures.

pH 7.0 pCO2 8 pO2 6 on arrival (they’re in kPa if you’re wondering)

Do they get the blue cigar?

Case 2

A young male presents via ambulance after being found agitated and delirious trying to catch a bus.

He is massively diaphoretic, agitated, tachy at 170 with a normal QRS but a dominant R in aVR. He is moderately hypertensive at 150 systolic. He tells you he wants to leave so he can catch his bus.

His lactate is 20 and he is producing dark coloured urine and has a CK greater than 100000.

Do they get the blue cigar?

Case 3

A middle aged male, with a preponderance to drink strong beverage and a tendency to have seizures, is found on the floor of a hostel seizing with a wound and grossly swollen right peri-orbital area. He has two further seizures on route to hospital and one in the department. It is now 30 mins from the first seizure and he has not returned to baseline.

Do they get the blue cigar?

Let me know in the google form and give some reasons in the comments. You’ll all want more information but you’re not getting any. I’ll give some follow up next week.