Making it Stick

I don’t know how much of what I “learned” in medical school I have since forgotten. It is a lot. Probably more than I remember. I did great on exams, but then it was time to move on to a new semester and piles of new information took priority over the old. There was no time to review or consolidate.

At the time, this just seemed like the way that learning was done. It wasn’t much different from my undergraduate routine: cram for an exam, get the marks, and move on to another topic. This was the way medical school was structured. The expert educators behind my medical school curriculum obviously knew what was best for me – right?

But where is all that knowledge now? Why did it feel like I had to start all over again in residency? Why do the residents I teach now, fresh out of medical school and close to that wealth of information, so often struggle?

We spend so much time trying to learn medicine, but we never really learn how to learn. This post is basically a review of the book “Make It Stick” by Peter Brown, Roddy Roediger, and Mark McDaniel.1 I wish I had been given this book before starting medical school. Actually, it would have been more beneficial before starting university, or even high school. It explains clearly why learning seemed so easy but ephemeral. I had excellent marks throughout high school and university – but if you made me take an exam from any of my past courses right now, I would almost certainly fail. Is that really learning?

These are the key lessons I wish I had learned long ago: Continue reading “Making it Stick”

Mending Medical Myths (lecture notes for St. Pauls Emergency Medicine Update 2016)

Medical myths matter. All of our decisions, although they often seem small to us in the middle of a busy shift, have real impacts on people’s lives. To be a truly expert clinician, you have to understand not just what to do, but why you are doing it.

The primary myth covered in this talk was the use of topical anaesthetics in the management of simple corneal abrasions. The full handout and list of articles can be found here.

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I also covered Salter-Harris 1 injuries, the myth that ligament is stronger than bone, and that concept that not all of these injuries need a cast. A full handout with references on the topic can be found here.

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If you are interested, a few of the other medical myths that I mentioned during the talk were:

The use of PPIs for upper GI bleeds

The benefit for stress testing in low risk cardiac patients

As physicians, we are trusted sources of medical information. We are relied upon not just by our patients, but also our families and friends to be knowledgeable and credible sources of information about health. We should all probably be aware of common medical myths, such as the need to drink 8 glasses of water a day, the idea that we only use 10% of our brains, or the thought that eating turkey might make you sleepy, because even these seemingly benign misunderstandings can have tremendous impacts on people’s lives. For a short, fun read on some of these topics, see:

Vreeman RC, Carroll AE. Medical myths. BMJ (Clinical research ed.). 335(7633):1288-9. 2007. PMID: 18156231 [free full text]

Charles Sidney Burwell, the dean of Harvard medical school at the time, famously said, “Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.” This may still be true today, but I don’t think this has to be true. If we taught the complexity of science, rather than just a collection of facts, we wouldn’t be wrong. We would understand the need for replication of studies and the limitations of p values. We would be able to differentiate treatments with great evidence (ASA in MI) from those with bad evidence (tamsulosin for renal colic), and we wouldn’t be so surprised by the constant updates that are part of the normal scientific process.

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There is a lot of evidence to keep track of and not many of us are laden with free time. How is one supposed to keep up with everything? In this day and age, I think the answer is crowdsourcing the work. There are so many great, free EBM resources available not that I don’t think there is any excuse in falling behind. This handout covers my favourite sources of evidence based medicine and critical appraisal.

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If anyone takes up my challenge and finds an interesting answer while exploring why we do what we do, feel free to contact me and we can share it here with everyone else. You can use this contact page or else e-mail me at first10em at gmail dot com.

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Emergent Cardiac Pacing

How to set up emergency cardiac pacing

Case

The 67 year old bradycardic patient from the previous case has a heart rate of 38 and a blood pressure of 68/45. It is time to start pacing… Continue reading “Emergent Cardiac Pacing”

Managing unstable bradycardia

A brief overview of the initial management of unstable bradycardia in the emergency department

Case

A 67 year old man is brought in by EMS after a syncopal episode at home. He has only partially regained consciousness, with a GCS of 12. His wife says that he has had a fast heart rate before and that he also has diabetes and high blood pressure. She isn’t sure what medications he is on. He has had flu like symptoms for a few days. The paramedic vital signs were a heart rate of 38, a blood pressure of 69/45, a respiratory rate of 22. The oxygen saturation tracing has been inconsistent, but they think it is probably about 91% on room air… Continue reading “Managing unstable bradycardia”

Articles of the Month (August 2016)

The best emergency medicine articles that I came across in August 2016

Welcome to another edition of my favorite emergency medicine articles of the month. Once again, there will be an accompanying podcast with the talented and insightful Dr. Casey Parker on the BroomeDocs website where we briefly discuss these articles. Continue reading “Articles of the Month (August 2016)”

High Sensitivity Troponin on the SGEM

It’s an SGEM hot off the press! That means that you can comment on this article, and potentially see your comments published next to the original article in the official version of Academic Emergency Medicine. I am also excited to be joining Ken Milne with Corey Heitz as the official co-hosts of the SGEM HOP AEM sessions.

This week, we discuss a new trial on high sensitivity troponin with the lead author and all round excellent chap Dr. Rick Body. Have a listen to the episode and post any questions or comments you have for Dr. Body on the website. It’s a great way to get involved in post-publication peer review. What to you think? Is a single negative high sensitivity troponin as a rule-out strategy ready for prime time?

Body R, Mueller C, Giannitsis E. The Use of Very Low Concentrations of High-sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test. Academic emergency medicine. 2016. PMID: 27178492 [Available free, full text here]

This is a secondary analysis of a large, prospective observational cohort (as part of the TRAPID-AMI trial.) They looked at 1282 adult patients presenting to the emergency department with new onset chest pain or symptoms suggestive of acute coronary syndrome that had peaked in the last 6 hours. The were looking at a high sensitivity troponin T on arrival and the primary outcome was acute MI at admission. The major secondary outcome was MACE (major adverse cardiac events). For the primary outcome of acute MI, using the primary strategy of an initial hs-cTnT below the limit of detection (<5ng/L) and no ECG ischemia, the test characteristics are:

  • Sensitivity 99.1% (95%CI 96.7-99.5%)
  • Specificity 43.9% (95%CI 40.9-46.9%)
  • PPV 26.0% (95% CI 23.0–29.2%)
  • NPV 99.6% (95%CI 98.5–100.0%)
  • LR+ 1.76 (95%CI1.67 – 1.86)
  • LR – 0.02 (95% CI 0.01 – 0.09)

In terms of the secondary outcome of MACE, the total 30 day event rate was 1.3%. The actual numbers were 6 MACE events, including only one death, no AMI and 3 revascularizations. I have always had a problem with considering revascularization as a adverse event, as it is so subjective. We know that revascularization is only helpful in the setting of an MI, so if someone goes for revascularization and didn’t have an MI is that really an important outcome, or is it just over-treatment?

My bottom line: Well, I don’t have high sensitivity troponin available, so I don’t have a use for this yet. There is no such thing as 0% risk. I think this information can be used to start a conversation with your patients. Within the context of shared decision making, I already send many patients home after a single negative troponin.

Go check out the episode on the SGEM, put on your skeptical hat, and make sure to comment.

Articles of the month (July 2016)

Another month and another edition of the articles of the month. However, this time I have some very exciting news. I have teamed up with Casey Parker (the brilliant, smooth-talking Australian physician, not the adult film star) to produce an audio version of these summaries. You will be able to find this podcast on http://broomedocs.com/, a great FOAM website that everyone should probably be following anyway. This is the first edition, and we will likely tweak the format with time, so if you have any feedback (hopefully more constructive than, “Justin, you have the perfect voice for silent films”), we would love for you to get in touch. Continue reading “Articles of the month (July 2016)”