For the unacquainted, START stands for Simple Triage And Rapid Treatment. This protocol aims to make triage extremely fast and simple to allow first responders to quickly assess large numbers of patients. Triaged patients are clearly marked with colors (black = dead, red = immediate attention, yellow = delayed attention, green = minor injuries).

As a mass casualty protocol may need to be taught to a large number of people quickly, it also needs to be intuitive. Unfortunately, in looking over the description in Rosen’s, I didn’t find that to be the case. Anyone that has read about this system in the past would have reviewed a flowchart that looks something like this:

Like some of the other Tiny Tips that I have/will publish, it is unlikely that emergency physicians will need to memorize this. However, it certainly could appear on a resident’s Board exam. My goal with the Tiny Tips is to find a way to remember things for these exams that I do not find intuitive. This flowchart definitely fit the bill.

A quick search found me the mnemonics 30-2-Can Do and RPM (Respirations, Perfusion, Mental Status) to help remember the criteria. This seems like a reasonable way to teach the system, but it didn’t stick with me very well. Instead, I decided to remember it by sticking with the absolute basics because the flowchart is really just the ABC’s complicated by arrows and colors. Here’s what my revised START flowchart looks like:

While this method of remembering the START triage system still requires memorization of some findings, I found that merging it with my regular assessment system (ABC!) was more intuitive than trying to remember an incomplete rhyme (30-2-Can Do) and relating those numbers to speed (RPM). Using the START protocol this way, the relationship between the criteria and the assessment of the ABC’s can be clearly seen.

This memory device, as well as the rest of the Tiny Tips, have been made into flashcards that can be downloaded and used as outlined on the Boring Cards page. Check them out!

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Brent Thoma

Emergency Medicine Resident at University of Saskatchewan

A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.

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The post Tiny Tips: START Protocol for Mass Casualty Triage appeared first on BoringEM and was written by Brent Thoma.

IS IT MEAT is a common mnemonic for this presentation and the best one that I have come across (thanks to Nadim Lalani from ermentor.com for teaching it to me and George Farjou for the quick comments to improve it). Not only do the letters have fairly intuitive meaning, but they also provide a structural approach with IS IT representing intracranial causes while MEAT represents extracranial causes.

Medical students, the next time an attending asks you for a differential of altered mental status, bust out something like this:

Altered mental status can be caused by intracranial and extracranial pathology. Intracranial causes can include… while extracranial causes can include… Based on this patient’s presentation, I think x or y is the most likely but can’t forget about a, b or c because missing them could lead to a disastrous outcome.

And they’ll think you’re all clever and organized and stuff.

While it’s a very good acronym, there are unfortunately a few things it doesn’t mention that are important to consider. Specifically, hypertensive encephalopathy and post-ictal state do not have a place (although they can lead to or be the result of some of the other things on the list).

This memory device, as well as the rest of the Tiny Tips, have been made into flashcards that can be downloaded and used as outlined on the Boring Cards page. Check it out!

Author information

Brent Thoma

Emergency Medicine Resident at University of Saskatchewan

A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.

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The post Tiny Tips: Altered Mental Status appeared first on BoringEM and was written by Brent Thoma.

Canadian FOAM of the Week: Sim and Choppers

Andrew Petrosoniak of Sim and Choppers is our FOAM of the week with his post on patient safety entitled “Patient safety strategies ready for primetime“. In this post, Andrew shares with us his thoughts on several recommendations published recently in the Annals of Internal Medicine on the use of checklists during critical patient care procedures.

Canadian FOAM: Honourable Mentions

•  Eve Purdy has a couple of new posts up at Manu et Corde this week, the first is a fascinating discussion of how twitter/SoMe was integrated into a classroom dialog to enhance the learning environment and the second is part 2 of a fairly comprehensive list of “Neurology Resources for Medical Students“.
• The SGEM brings us Episode #36 “Mac and CCBs” where Ken Milne answers the question “Do macrolides cause serious hypotension in patients on CCBs?”.

Canadian FOAM: Hat Tips

• Danica Kindrachuk shares some entertaining vignettes from her attempts at studying neurology and other subjects over at Want2BeMD this week.

Author information

Joel D'Eath

Advanced Care Paramedic

I love tinkering with technology, the outdoors, photography and playing with my kids. In an attempt to delay the onset of dementia, I'm learning to play the bagpipes...

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The post Canadian FOAM of the Week 009: Sim and Choppers appeared first on BoringEM and was written by Joel D'Eath.

I figured that if I was going to invest all of this time making these flashcards, I better do it right the first time. The more of them I made the more difficult it would be to convert down the road. And so I began a search for the ultimate flashcard program. I had no idea what I was getting myself into.

There are a TON of flashcard programs and apps. So many, in fact, that a website was even made to with the sole purpose of comparing them! My first step was to define the features my “ideal” program would:

• Incorporate spaced repetition
• Multiplatform (Android/iPhone)
• Compatible with other flashcard apps
• Syncable with a cloud system
• Great interface
• 5-star user reviews
• Affordable on all platforms
• Allow for images

It took me quite awhile, but I think I found a combination of an app and website that can almost do it all.

The App: Flashcards Deluxe

Flashcards Deluxe is a boringly named multiplatform app with amazing reviews, an intuitive interface and great user reviews that incorporates spaced repetition. For easier flashcard-making, it is compatible with two prominent online flashcard repositories – Quizlet and Flashcard Exchange. It retails for a one-time cost of <$5 on the App Store and Google Play. While it does sync its spaced repetition data with Dropbox and/or Google Docs, the platforms that I prefer to make/edit my cards on does not automatically sync. This is a small inconvenience that I think is overcome by the benefits that come with using this app.

The Platform: Flashcard Exchange

As part of the switch, I’ve converted my flashcard decks to Flashcard Exchange. I chose this platform over Quizlet because it allows images to be used on the cards without additional fees. A bonus of hosting my cards on Flashcard Exchange is that they are easily downloadable to Flashcards Deluxe as well as most other flashcard apps. If you prefer another app to Flashcards Deluxe (or have already purchased one) it is likely that you will still be able to make use of cards hosted here.

Conclusion

I think this is a great way to go for my own studying and it is what I would recommend to any FOAMites considering making their own flashcards and willing to share. Within the next day or so, the AnkiEM Project page will undergo a renovation to reflect this switch. In the meantime, if you’re interested in checking out my decks (Rosen’s Chapters 145-155 are finished) you can download them off of Flashcard Exchange (just search BoringEM). In addition to the Rosen’s chapter reviews, I will also be making a deck summarizing the memory devices used in each of the BoringEM Tiny Tips.

I am still quite open to feedback on my app/website choices… but I don’t particularly want to convert to another entirely new platform!

Author information

Brent Thoma

Emergency Medicine Resident at University of Saskatchewan

A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.

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The post AnkiEM Evolution – Flashcard Exchange & Flashcards Deluxe appeared first on BoringEM and was written by Brent Thoma.

This is the first BoringEM “Tiny Tip.” While most of my medical posts are quite long, I think there is some merit to occasionally going over something small and simple. “Tiny Tips” will outline mnemonics and other memory devices that I use as I start studying for my Royal College exams. They will also be summarized on a deck of “Memory Aids” that I will soon make available as part of the AnkiEM project.

Here’s what I came up with:

As outlined in Rosen box 149-1, the major pharmacodynamic effects of TCA’s affect neurotransmitters and ion channels. Acknowledging that 8 effects are not easy to remember, I reclassified them so that they’d fit the easy to recall mnemonic TCA and so that each letter would have 3 actions (I added the effect “Antidepressant” to balance things out). The potential complications of each effect in an overdose are outlined in brackets.

T is for “Thinker”

I know that’s not completely intuitive, but hopefully it’s odd enough for you to remember that it refers to TCAs brain/psychiatric effects. The Thinker effects of TCAs are:

1 – Indirect GABA antagonism (seizures)
2 – Serotonin reuptake inhibition (serotonin syndrome and agitated delirium)
3 – Norepinephrine reuptake inhibition (initial hypertension and agitated delirium)

C is for “Cardiac”

This one is a little more intuitive. The Cardiac effects of TCAs are:

4 - Na channel blockade in phase 0 of cardiac depolarization (wide QRS, impaired inotropy)
5 – K efflux blockade prolonging phase 3 of cardiac repolarization (long QT)
6 – Alpha-1 adrenergic blockade causing vasodilation (hypotension)

A is for “Anti.”

The anti-something effects of TCAs are:

7 – Anticholinergic (delirium, seizures, sedation, coma, prolonged gastric emptying)
8 – Antihistamine (I don’t believe this causes any problems in OD)
9 – Antidepressant (this actually results from the Norepi/Serotonin reuptake inhibition, but it balances out the acronym!)

Hopefully this acronym will help you to remember this somewhat obscure bit of trivia for your exams or at least facilitate some seriously tortuous med student “pimping.”

Stay tuned for more BoringEM Tiny Tips by following on twitter, signing up for e-mails or following the RSS feed. All of the links are in the side column. Thanks for reading!

Author information

Brent Thoma

Emergency Medicine Resident at University of Saskatchewan

A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.

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The post Tiny Tips: The Effects of TCAs appeared first on BoringEM and was written by Brent Thoma.

Dr. Strayer‘s strategy for studying for his board exam was to summarize Rosen’s Emergency Medicine onto flash cards. In the spirit of FOAM, he then scanned all 1412 cards onto his EM Updates site and made them freely available. If you haven’t already checked them out I recommend you do. They’re quite the repository of knowledge.

Dr. Nickson‘s post provides a great summary of the concept of spaced repetition and related learning theory so check it out if you’re intrigued by the idea. Effectively, the theory posits that repeated exposure to concepts using the ‘spacing effect’ helps us to retain knowledge. This chart provides a great visual summary:

Original image credit to http://www.wired.com/medtech/health/magazine/16-05/ff_wozniak?currentPage=all. I found this picture through Chris Nickson’s post here http://lifeinthefastlane.com/2011/11/learning-by-spaced-repetition/

Dr. Nickson‘s post also introduced me to Anki. Anki is a flashcard program that has built in spaced repetition. Each version tracks your correct/incorrect responses to the cards and shows you the ones that you got incorrect more frequently until you learn the material. Effectively, it helps you to focus on the concepts you don’t know while at the same time using spaced repetition to reinforce the ones that you do. Text, sound and images can be embedded in the cards. It is available for use free on the web, Android has a free 3rd party viewer and the real app is $25 on an iPhone. As always, I have no conflict-of-interest with any of these programs – no one pays me for anything.

I imagine you can see where I’m going with this. Over the next few weeks I will be trialing the creation of Anki decks that summarize each chapter of Rosen’s Emergency Medicine. While I’m not sure that they will be useful to anyone other than me, in keeping with FOAM I will make them freely available in as many ways as my technologically-challenged mind can handle (likely for download from BoringEM and importing from Anki). If I found that the creation and review of the cards is valuable this will likely become my preparation for the 2015 Royal College EM exam.

As I am on my toxicology rotation right now, I have started creating decks for each of the toxicology chapters. When they are available they will be posted with instructions on how to use them on a page that will be linked to at the top of my site between the “Disclaimer” and “Write for BoringEM” tabs. Look for them later this week.

In the mean time, I would appreciate some feedback. Do you think this will be an effective way to study? Would you be interested in using the cards? Could Anki work for you as a viewer (despite the high price of the iphone app)? Would you suggest any alternatives? I’d like to get this right before I put in too much effort. Any thoughts would be appreciated.

Author information

Brent Thoma

Emergency Medicine Resident at University of Saskatchewan

A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.

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The post The AnkiEM Project appeared first on BoringEM and was written by Brent Thoma.

There are some fantastic posts this week, on a variety of interesting topics. It seems this was a very prolific time period for some of our bloggers.

Must be a spring thing…

Canadian FOAM of the Week: SOCMOB

SOCMOB has done it again with his post “Digital Intubation, And I Don’t Mean Video” to take the Canadian FOAM of the Week distinction. He uses pictures, humour and a strange YouTube video to help explain an under utilized intubation technique that should be part of every advanced airway providers tool kit, especially if they frequently find themselves in awkward airway scenarios where all the fancy tools at thier disposal may not be useful.

Canadian FOAM: Honourable Mentions

• Our top honourable mention this week goes to Eve Purdy for having no less than 3 new posts this week on her blog Manu Et Corde. There’s a bit of math to help you solve last weeks probability conundrum, a post on whether “To Suture, Or Not To Suture?” and even a guest post from her classmate Amanda Murdoch entitled “What Does Advocacy Mean To You?“.
• ElishaT over at The Chart Review has posted an excellent case study that reminds us to look past the obvious when evaluating our patients, and dig deep to avoid missing potentially fatal DDX in “A Clear Cut Case Of Acute Coronary Syndrome (?)“. Well laid out, lots of references and some excellent learning points with regards to cognitive errors/bias.
• Apparently I missed a post by ERMentor last week on the futility of certain routine blood draws in the ED. Check it out here at “Type & SCREAM Stat! Futility Of Ordering Routine Blood Type & Screens In The ER“.

Canadian FOAM: Hat Tips

• Hat Tip the first goes to Andrew Petrosoniak at Sim & Choppers where he discusses the use of a “Hybrid Simulation” model using actors and Sim People to increase the fidelity of medical simulation. Interesting stuff, read it at “Hybrid Simulation… Using Patient Actors To Enhance Simulation“.
• Danica Kindrachuk of Want2BeMD fame introduces us to what looks to be a very useful collection of flow charts linking a disease’s pathophysiology to patient presentation & more. That post is called “A Wonderful Guide To Understanding Disease“, head over and check it out, I don’t think you’ll be disappointed.
• SGEM #35: We Are Young from Ken Milne presents 3 individuals’ views on social media and medicine along with Ken’s own thoughts on the subject. Interesting read, good points and a lot to think about after reading it.
• Our own Brent Thoma has a post up this week on BoringEM.org reviewing a portable ultrasound machine… Interesting stuff as something this small could be carried by Paramedics… Hmm, Pre-hospital FAST scans anyone? For the full meal deal click on “Handheld Ultrasound – A Review Of The VScan“.

That’s it for this weeks round up, check back next week for more Canadian FOAM content produced by Canadians for all to enjoy.

Author information

Joel D'Eath

Advanced Care Paramedic

I love tinkering with technology, the outdoors, photography and playing with my kids. In an attempt to delay the onset of dementia, I'm learning to play the bagpipes...

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The post Canadian FOAM of the Week 008: SOCMOB appeared first on BoringEM and was written by Joel D'Eath.

For the unacquainted, the VScan is a “pocket-sized ultrasound” made by GE that retails for approximately $7,900. Details for the hardcore interested are available here. It comes with a 4GB micro-SD card (you can substitute a larger card if you need) for image capture and one phased-array probe. It has preprogrammed presets for cardiac, abdominal and obstetrical scans and is advertised as also also being suitable for urology, peripheral vascular and pleural fluid/motion detection.

Before I start – a disclaimer. I would describe myself as a low level EM ultrasound user. I am an independent practitioner (IP) as certified by the Emergency Department Ultrasound Society in Canada and have instructed with the EDE1 course that covers the four primary indications (aortic aneurysm, subxiphoid view pericardial/cardiac standstill, intrauterine pregnancy, FAST) twice. While I have taken the EDE2 course (advanced applications such as parasternal/apical cardiac, DVT, pneumothorax, gallbladder, etc), I have only had a sufficient number of proctored/confirmed scans to feel comfortable in my use of ultrasound for pneumothorax and arterial & central line placement. For this reason, I will only review the VScan‘s usefulness for these scans and in the context of my residency program. I imagine that you’ll find this review much more useful if you are a trainee like me or someone similarly middling in your skillz. I imagine that more expert users, and especially those with substantial experience with the VScan, would be able to obtain better imagines and might review the product more highly.

As I’m discussing a product I feel like I should also reiterate the conflict-of-interest statement in the disclaimer section of BoringEM. To summarize, I have no money to invest in anything and nobody values my opinion enough for someone to want to pay me for it so I have absolutely no conflict-of-interest that relates to this product.

Onto the review!

VScan Portability – 3.5/5

Portable or not, in practice I didn’t carry the VScan around with me. Despite being advertised as “pocked-sized”, I found it too big and heavy to carry comfortably in my scrub pocket (although it did technically fit) and I would have been concerned that I would drop/break the probe during regular ED shift activity. It generally sat in its case at my desk until it was needed. Suffice to say, I think ultrasound technology still has a way to go before I will carry one around my neck like this:

Follow @squartadoc, the Twitter account responsible for sharing this epic image.

I look forward to the day when I can get wireless ultrasound probe(s) that transmit images to my smartphone over bluetooth and come with a sturdy clip to attach to my scrubs! With that being my 5/5 ideal, I give it a 3.5/5 because it is still substantially more portable than the M-Turbo that I’m used to. Interestingly, occasional BoringEM author Paul Olszynski (who also peer-reviewed this post and is currently enhancing his ultrasound skills in England) has also trialed the VScan and felt it was very easy to walk around with. To each their own!

VScan Battery – 4.5/5

I found the battery life was more than adequate to last a few shifts at a time. I docked 0.5 star because the charging station was pretty bulky for sitting around my house where it slept. It would be a great station for an ED-based VScan.

VScan Quality

I’ll rate the VScan on its usefulness this scan-by-scan after a single month of use. In general, I found that while it is very small, I found the single phased-array probe to be limiting. Combining this with a smaller screen size and less resolution than what I am used to getting from my buddy the M-Turbo, I found it more difficult overall to produce adequate images. However, I did get better as I better with ongoing use over the month. The 5/5 comparable for these rankings are the subjective images that I am able to produce with an M-Turbo.

Aortic Aneurysm – 3.5/5

I found it substantially more difficult to get a conclusive aorta scan with the VScan. I imagine this was due to a combination the smaller screen, the decreased frequency, and the smaller size of the phased array probe. I found bowel gas to be more problematic than useful because the smaller probe head reduced the amount of pressure that I could compress with while keeping the patient relatively comfortable. My peer-reviewer Paul Olszynski pointed out that this may have been ameliorated by simply using something blunter (like my hand!) to provide pressure. Like usual, he’s right, so I added a 0.5 star onto my original score of 3.

Subxiphoid Cardiac – 4.5/5

Phased-array probes were basically made for cardiac scans and you can tell. I got great subxiphoid images and even some good (for me) parasternal and apical views. I still felt the small screen limited my image quality, but imagine that would continue to improve with practice and my ultrasound skills. The cardiac preset was a great starting point to get a solid image on most patients.

Intrauterine Pregnancy & Abdominal Free Fluid – 4/5

I found both of these scans to be pretty decent with the VScan. I’m sure a larger screen would have helped to better visualize earlier gestation pregnancies and small slips of free fluid, but I was able to consistently get relatively good quality images. The presets for these scans were great starting points for most patients as well.

Pneumothorax – 2.5/5

I generally do this scan with a high frequency linear array probe with multi-beam off, so the picture I saw with the VScan was quite different and that made me less confident in my interpretation. The probe fits nicely between ribs, but there was no pulmonary preset and despite messing with the gain and depth with ferocity, I still found that the images I produced were inferior.

Vascular – ?/5

Honestly, I never even tried to use the VScan for vascular applications. I was taught to do vascular scans using a high frequency linear array probe and didn’t even think to attempt looking at the vasculature with the phased array probe until reading the product description on the GE site.

Unanticipated Benefits

Besides the obvious benefit of being able to work on my ultrasound skills while on a rotation during which I would have otherwise not scanned anyone for a month, there were two unanticipated benefits to using the VScan:

1 – It allowed me to be an ambassador for POCUS (point-of-care ultrasound)

I think bringing a handheld ultrasound with me on my rotation was a good exposure for a department that had yet to develop their own EM ultrasound program. The nurses asked what it was and saw the utility of showing worried pregnant women visual confirmation of their baby’s beating heart (see this small study by my PD that showed a reduction in miscarriage rate from ~80% for a scan that was nondiagnostic of intrauterine pregnancy to ~15% for a scan showing a live IUP). The doctors were keen to discuss ultrasound applications and talk about their efforts to acquire a machine in the very near future. I anticipate that when our residents carry the VScan around with them on off-service rotations in our center there may be similar interest from general surgery, obstetrics, internal medicine and anesthesia residents and staff. I can only see the further exposure to POCUS that results from a walking ultrasound machine helping to facilitate its wider adoption.

2 – I looked really cool walking around with it

Or at least I thought so… I didn’t take a picture, but in my head I imagined that I was giving off a cutting edge impression. In retrospect, I may have actually looked like this guy:

Conclusion

I think the VScan is a solid portable ultrasound device that, in skilled hands, can provide adequate images for a number of important scans. I think it is a great purchase for our residency program where it will be lent out to residents on off-service and off-site rotations to help them maintain their basic skills while demonstrating the benefits of POCUS around our health region. However, in my home ED I would stick to my trusty M-Turbo any day of the week. I look forward to the day when I find an ultrasound machine portable and convenient enough to carry around and use like a stethoscope, but unfortunately the VScan is not that device for me.

Have you used the VScan or a similar handheld device? What did you think? Get back to me in the comments or on twitter.

Peer reviewed by Paul Olszynski

Author information

Brent Thoma

Emergency Medicine Resident at University of Saskatchewan

A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.

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The post Handheld Ultrasound – A Review of the VScan appeared first on BoringEM and was written by Brent Thoma.

Anyway, on a brighter note, the FOAM selection over the last 14 days has been fantastic. We have a new blog that was added to our blogroll during this period, and this blog has the distinction of being our Canadian FOAM of The Week…

Canadian FOAM of the Week: Sketchy Medicine

The newest addition to the Canadian FOAM list comes via Ali Martin and her blog Sketchy Medicine. Ali is not only a physician but also a trained illustrator, in her blog she has managed to combine both talents most impressively. Her post this week on “Maculopapular Childhood Rashes” is fantastic. It is a simple, straightforward explanation of the common rashes seen in the paediatric population accompanied by her own illustrations.

I am, quite frankly, blown away at the quality of Ali’s illustrations along with her generous offer to use them in your own projects (with proper attribution, of course.). I encourage everyone to swing by and check out her other posts as well.

Canadian FOAM: Honourable Mentions

• On the FOAMed front we have SGEM Episode #34: This is Spinal Tap.The podcast and accompanying blog post run through a Lumbar Puncture procedure with an eye towards reducing adverse effects experienced by the patient. Some solid info here, and a great illustration of patient positioning for the procedure.
• Paul Kulyk has an interesting post called “Evidence for Mortality Benefit of Helicopter EMS” on his blog this week. I believe the genesis for this post was a twitter conversation about HEMS in Saskatchewan and his curiosity about whether it is as cost effective and life saving as we believe it to be. His post describes his literature search and includes a link to a PDF of the results. This is a particularly relevant topic as HEMS utilization is a hot button topic worldwide, along with here in Ontario.
• Eve Purdy from Manu et Corde brings us 2 great posts this week and I enjoyed reading them both! “How Long is Long Enough? An evidence-based look at CPR duration” is a guest post on the blog by Heather Johnson that discusses the subject of lengthy CPR attempts and how that relates to patient outcomes after an in-hospital cardiac arrest. My colleagues & I regularly run into the out of hospital cardiac arrest scenario, and one of the many issues we encounter is when to stop resuscitation. This post has done an admirable job of discussing that topic and what it means to patients & their family members that is relevant no matter where you practice.
• Chris Bond over at SOCMOB  has a fantastic post called SOCMOB How To: Jet Insufflation and Bougie Assisted Cric. This post is a follow up to a previous post on making a DIY cricothyrotomy trainer (that you can find here) and adds a couple more videos on how to use the DIY trainer to practice Jet insufflation & bougie assisted crics. I love this post because I don’t normally have access to a cric trainer, and this will really help fill a void for me training/skill retention wise.
• If you’ve been looking for solutions to keep your blogs/journals etc. organised (beyond lists like ours and over at LITFL) Andrew Petrosoniak has written an interesting post at Sim and Choppers called Information overload…staying up to date with new medical journal publications where he discusses a few different ways he has used to keep organized. He invites readers to add their own solutions in the comments, so share away!

Canadian FOAM: Hat Tips

• Our first tip of the hat this week goes to Ken Milne and his post sharing his reflections on his experience at the 2013 Boston Marathon. We’re glad he’s okay and grateful that he has chosen to share this with us online. It’s called SGEM #33 Boston 2013 and I recommend everyone give it a read.
• Over at Asystole is the Most Stable Rhythm we find a post depicting the chaos of moving countries while revising for medical school exams. If you’re in the mood for a little light hearted fare, have a look at “Oh Our Lives” .
• Two posts up on BoringEM this week one from Brent Thoma entitled “Choose Your Own Adventure” touches on the many different ways a medical student can integrate their personal interests into their burgeoning medical careers. Our newest author, Chris Byrne leaps out of the starting gate with “Point of care Ultrasound: a hyperechoic future in Med Ed?” which paints a very exciting picture of a future where the bedside ultrasonography is the new “Stethoscope”. A good, solid read with many references to get the reader engaged in the discussion with.

Stay tuned for next weeks round up… Till then, happy reading and please forward any other Canadian authors of FOAMed our way for inclusion on the Canadian FOAM list.

Author information

Joel D'Eath

Advanced Care Paramedic

I love tinkering with technology, the outdoors, photography and playing with my kids. In an attempt to delay the onset of dementia, I'm learning to play the bagpipes...

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The post Canadian FOAM of the Week 007: Sketchy Medicine appeared first on BoringEM and was written by Joel D'Eath.

Technological advancements perhaps too often remove the physician and learner from the bedside.  Subjectively, I couldn’t help but notice that this assessment advanced the therapeutic relationship in a positive, patient-centered way.  I also realized the tremendous untapped potential of the use of point of care ultrasound (POCUS) in medical education.  In my eyes, this modality safely removed the sometimes frustrating – yet often necessary – barrier between knowledge and experience that is all too familiar during our training.

Image used with the permission of the Department of Radiology at the University of Texas Health Science Center at San Antonio

What is Point-of-care Ultrasound?

Point of care ultrasonography refers to ultrasonography performed, interpreted and integrated in to the patient care plan by the physician in real time at the bedside.  Images are obtained immediately and dynamically, permitting direct correlation with the patient’s presenting signs and symptoms.  In addition, POCUS can be quickly repeated if the patient’s condition changes.  Due to some comparable qualities to the physical exam, some authors have gone so far to call POCUS a “visual stethoscope.”

POCUS in undergraduate medical education is generating passionate discussion.  As portable and handheld ultrasound devices become increasingly affordable, many institutions south of the border have already or are in the process of formally implementing ultrasound training in to their curriculums.  Some of these schools go as far as providing first-year students with these handheld devices in addition to the stethoscopes and reflex hammers we are accustomed to.

How should Point-of-care Ultrasound be taught?

While there are different views on how physicians should be trained in ultrasound, many believe that much like percussion, stethoscopy or fundoscopy, POCUS will evolve into a core competency of medical training.  Stated another way, you can think of POCUS as a modern extension of the physical examination as we presently know it.  POCUS has the benefit of providing supplemental, immediate and dynamic information at the bedside that helps address focused clinical questions.  However, as with any physical exam skill, we must be cautious and appreciate variation in quality and skill among different users at different levels of training.  Ultrasound images may be easily recorded and archived using programs such as SWS and Q-Path permitting asynchronous review of findings by supervisors and allowing a higher level of oversight and accountability compared to physical exam.

Point-of-care Ultrasound in Canada

In Canada, POCUS training is typically limited to the resident level and above.  There are, however, some working groups at medical schools across Canada lobbying curriculum administrators to consider POCUS training at the medical student level.  At my home institution, pre-clerkship students were exposed to POCUS in the anatomy lab for the first time this academic year.  Most senior medical students have encountered bedside ultrasound assessments in action in at least one of their clinical rotations through the emergency department, intensive care unit or operating rooms.

Follow @squartadoc, the Twitter account responsible for sharing this great image with the #FOAMed community!

Outside the classroom, a local and growing grassroots movement has many students excited for the future of medical education.  Great things are happening at Schulich, an institution aiming for the best curriculum on earth by directly involving students in the medical education discussion.  In September 2012, the POCUS interest group was launched within Schulich’s robust medical student club system.  The club has attracted over 100 students in its inaugural year.  We’ve hosted a number of hands-on events – from scanning for abdominal aortic aneurysms and pericardial effusions to inserting central lines – that have generated rave reviews and an increasingly passionate core of sonophiles.

Of course, we could not have accomplished this without the support of keen residents, fellows and faculty members whose contributions to the interest group have been immeasurable.  This passion has persevered throughout the year, now culminating in the organization of an innovative two-day event, the Western Medical Student Ultrasound Symposium, to take place on August 24, and 25, 2013.  This symposium is the first of its kind in Canada and is attracting interest from faculty and medical students from institutions across the country.

In the coming weeks, the POCUS interest group will be having a discussion on ultrasound in medical education.  This topic will also be brought up at the August symposium.  There are some fantastic #FOAMed (Free Open Access Meducation) resources out there on ultrasound in medical education, two of my favourites being the Ultrasound Podcast (episodes 40, 41 and 42) and a written piece at SonoSpot.

Barriers to Ultrasound Integration

Experience from other institutions reveals some of the obstacles to integrating POCUS – or any new topic, really – into an established medical curriculum.  With limited classroom time and a breadth of evolving technologies and progress in medicine to represent, tough decisions regarding curricular content must be made.   Uniquely, ultrasound does not demand standalone course time.  Though destined to be a tool of clinical value to medical students in their clerkship years and beyond, introductory ultrasound training may occur through integration in to existing core curricular activities such as anatomy and physiology.  In this fashion, ultrasound enriches, rather than competes for, existing classroom or lab experiences.

Conclusion

The past year has been a fun and rewarding ride, from the initial zeal on wheels of that consultant in the emergency department to a growing group of forward-thinking students who are a pleasure to work with. A final comment to my medical student colleagues, taken directly from the opening sequence of the Ultrasound Podcast: Get out there, ultrasound some hearts, some lungs, some IVCs and let others know how you feel about it!

I look forward to what I believe will be a hyperechoic future for medical education.

Peer reviewed by Robert Arntfield of Western Sono and Brent Thoma of BoringEM.

Author information

Chris Byrne

Medical Student at University of Western Ontario

Chris is a senior medical student with interests in emergency medicine, critical care and point of care ultrasound. He sees untapped potential in the use of point of care ultrasound as a teaching tool in undergraduate medical education.

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The post Point of care ultrasound: a hyperechoic future in Med Ed? appeared first on BoringEM and was written by Chris Byrne.