clinical skillset: bite-sized task lists

leaving it here for storage/reference, but if you happen to come across this:

via “Master Clinicians Address Large Problems One Step at a Time” by Richard M. Levitan, MD

Key takeaways:

–master clinicians reduce cognitive burden (brought on by critical/complex patients, multitasking, etc) by tackling the next [few] steps only, accomplish those, then tackle the next task(s) in bite-sized attainable pieces.

–key section of the article: “Master clinicians, who walk into complete chaos with a smile, maintain their cool, and inspire confidence from the team, do not worry about everything. They have insight into the priorities of the situation. They take small incremental steps, fixing one problem, then the next, until it’s clear they have command and control of the situation, making forward progress in the face of great challenge.

Operating “in the zone” is not about struggling to do everything at once; it is the exact opposite. A lightness of being, an unburdening of mental load, “just doing, not trying”—this is the inside secret of those in all areas of life who perform mightily in the face of enormous stress and terrific challenge.

We have all seen novice clinicians struggling in a crisis situation, overthinking and trying to figure out what is the right thing to do. Conversely, experienced clinicians calmly and with relaxed focus are able to just perform. “

–“The best clinicians engineer their practice—it is not just they are skilled and experienced. Having deliberately engineered their performance into small, simple, reproducible, and reliable steps, they have lowered the task complexity. …The secret to procedural performance is compartmentalization, incrementalization, and repetitive practice.”

Some good mental models to incorporate into your clinical practice, if its not already.  The article is worth a read too, when you have a moment.

References: article; picture

 

intraoral ice for epistaxis?

haven’t posted in ages, using this mostly as a storage place for info, but if you happen to come across this, here’s some limited data:

(via abstracts, as full text not available online for me, and in-person not available due to COVID):

 

Porter MJ. “A comparison between the effect of ice packs on the forehead and ice cubes in the mouth on nasal submucosal temperature. ”

• 13 subjects
• ice pack to forehead, ice cube to suck on
• ice cube to suck on reduced nasal temperature

Porter M, Marais J, Tolley N. “The effect of ice packs upon nasal mucosal blood flow.”

• 16 patients
• ice pack on forehead vs. ice pack in mouth
• no changes with forehead ice, but…
• “Ice packs within the mouth produced a significant decrease in nasal mucosal blood flow (p less than 0.05). The average fall was 23%“

 

Bottom line: small studies, but low harm profile.  seems like ice chips (or popsicle for kiddos) to floor of mouth is worth a shot when possible in epistaxis (assuming the bleed isn’t so bad they need to focus on oral airway patency)

 

References: article 1, article 2, photo

visual aid: breech delivery

the most commonly referenced delivery maneuver seems to be the Mauriceau‐Smellie‐Veit maneuver:

the basics to get to that point seem to be:

–wait till you see the popliteal fossa, then sweep/deliver the leg

–wait till you see the scapula border, then rotate gently and sweep/deliver the arms

–wait till you see the nape of the neck, then deliver with the MSV maneuver

 

quick snapshot visual aid:

 

quick video visual aid (relatively short, with decent audio):

 

There you go. Add it to the emergency toolbox.

 

References: guidelines, photo visual, video visual

NG tube utility in bowel obstruction

another food-for-thought tidbit after a bit of a long layoff…

 

Best BETs from the Manchester Royal Infirmary. BET 1: Is routine nasogastric decompression indicated in small bowel occlusion?

–found all of one useful/relevant paper (below)

 

Fonseca et al: Routine nasogastric decompression in small bowel obstruction: is it really necessary?

• Key points:
  • 65-80% of SBOs (small bowel obstructions) are treated non-operatively (bowel rest, IVF, obs)
  • NG (nasogastric) tube often used for decompression
  • NG tube complications can include: pneumothorax/perf, pneumonia, nasal trauma/infection, patient discomfort, etc.
• Retrospective study highlights:
  • 290 patients >18 yo with SBO
  • causes included adhesions, malignancy, unknown (excluded incarcerated hernias)
  • 235 patients got NG tubes (so 55 didn’t)
  • NG tube was not associated with avoidance of surgery
    • 37% (87/235) with NG tubes needed OR intervention
    • 24% (13/55) without NG tube needed OR intervention
  • Days to resolution (average)
    • 3.55 days in NG tube group
    • 1.67 days in non-NG tube group
  • Hospital length of stay (average)
    • 10.16 days in NG tube group
    • 3.18 days in non-NG tube group
    • similar trend excluding the patients who needed OR intervention
  • Significantly higher rate of pneumonia in the NG tube group (11.59% vs. none, P=0.007)
  • author conclusion: “…we recommend the judicious use of NGT, especially in patients presenting without emesis.”

 

old article, but often cited: Singer et al: Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures

• most painful procedures according to patients (in descending order)
  • nasogastric intubation
  • abscess drainage
  • fracture reduction
  • urethral catheterization

 

Food for thought.

 

References: Best bet article, Fonseca article, Singer article, picture

visual aid: Davos shoulder reduction

here’s a couple quick visuals to help add this shoulder reduction technique to your bag of tricks (which worked in 86/100 patients in one study):

Note: if you only have 1 minute, start watching at the ~1:30 mark.

 

as opposed to the video, the article suggests wrapping the elastic bandage around the leg as well, which means you don’t have to rely as much on the patient to keep their arms in position (makes sense to me).

 

There you go. Add it to the toolbox.

 

References: article; video; picture

 

visual aid: slit lamp tutorial

a nice quick video tutorial on the slit lamp exam from this old ALiEM post:

if you only have a couple minutes, the ~2:00 to 4:00 minute mark are nice reminders of a few knobs and how to adjust the level and light window.

also, there’s a nice example of cell & flare at the ~5:30 mark.

Go forth, look at eyeballs.

 

References: ALiEM post (with other eye exam videos also)

IO craniotomy?

back after a bit of a layoff with a bit of an interesting, if maybe not ready for primetime procedure idea, via this Austrailian resus blog:

basically, in the setting of an expanding intracranial hematoma, evacuating the pressure to temporize (the alternative being herniation, then death).

while burr holes are preferred, if you have nothing else, interesting to see this on the horizon as a potential option.

 

References: resus blog post & photo