Loading...

Follow Down East Emergency Medicine on Feedspot

Continue with Google
Continue with Facebook
or

Valid
   WHAT IS METACOGNITION? Metacognition is “thinking about thinking.” The current popular theory of how we think is called the Dual process theory. The dual process theory is a cognitive psychology theory that explains the different levels of information processing in individuals. It is classically defined as type I and type II thinking. Whether we are aware of it or not, we use these types of thinking to structure our medical decision making about our patients.   https://www.acutemedicine.org.uk/wp-content/uploads/2016/09/4.3-Nicholl.pdf SEVEN METACOGNITION HACKS TO MAKE YOU A BETTER DIAGNOSTICIAN 1. Practice Early in training we are more likely to be confident but less likely to be right. Accumulating “mentally stored exemplars” will expand the accuracy of your type 1 thinking. To solidify your type I thinking, follow up on your patients to confirm your clinical gestalt. 2. Flip the switch Deliberately “toggle” from type 1 to type 2 thinking in tough cases AND in “easy” cases to check your thought process. Ask yourself - what evidence goes against my diagnosis? What’s the worst thing I could miss? 3. Take a diagnostic pause Take a moment to let your cognition work. Write down your medical decision making or present the case to a colleague. This helps “flip the switch” and also “cognitively unloads” the workup. 4. Use “cognitive forcing” This metacognition trick helps you avoid “can’t miss” diagnoses or high-risk errors. Examples include consistently screening for the “red flags” (e.g. fever) in low back pain or never diagnosing renal colic in an elderly patient without first thinking of a ruptured abdominal aortic aneurysm. Using “smart phrases” in the medical decision making section of the electronic health record can serve as a checklist (and force you to consider high risk diagnoses). 5. Manage the cognitive load Too much cognitive load triggers the “cognitive miser” function, which favors type 1 thinking and avoids type 2. Make dispositions, unload decisions, and run the list. Clear out the “mental baggage” that is slowing you down. 6. Beware of common cognitive bias that can sabotage your decision making. Affective bias: Be careful not to let how you feel about the patient affect your reasoning. It is easy to be biased against certain patient populations that are difficult. Eg. “He’s really belligerent and rude. I bet he’s just drunk again.” Framing bias: Geography does not dictate pathology. Eg. Don’t just assume wellness in the “fast track” patient because they weren’t triaged a higher acuity. Availability bias Sometimes clinicians choose the most available diagnosis that comes to mind. Eg. Everyone you’ve seen lately has had “the flu”, and you assume it is the most likely the cause of your patient’s fever. Anchoring bias The tendency for clinicians to stick with the initial impression even as new information becomes available. This is often worsened by confirmation bias (the tendency to accept new information only if it confirms the working diagnosis). Eg. You assume the young person with chest pain is likely musculoskeletal in origin (despite him describing radiation to both shoulders). 7. Defend against depletion. Attend to your nutrition, hydration, and brief “cognitive pauses” (I recommend dark chocolate!). Rest is not selfish—it’s better for our patients!  Tired of reading? Prefer to absorb your MedEd through your wonderful powers of hearing? Listen to the podcast below. References Campbell A et al. Profiles in patient safety: a “perfect storm” in the emergency department. Acad Emeg Med 2007; 14: 743-749. [Pubmed] Crosskerry P.  ED Cognition: any decision by anyone at any time. CJEM 2014; 16(1):13-19. [Pubmed] Crosskerry P et al.  Cognitive debiasing 1: origins of bias and theory of debiasing.  BMJ Qual Saf 2014; 22:ii58-ii64. [Pdf] Crosskerry et al. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013; 22:ii65-ii72. [Pubmed] Crosskerry P.  A universal model of diagnostic reasoning.  Acad Med 2009; 84(8):1022-1028. [Pdf] Kahneman D (2011) Thinking fast and slow. New York, NY: Farrar, Strauss, and Giroux. [Amazon] Peer Reviewed by Jeffrey A Holmes, MD and Jason Hine, MD Posted by Jeffrey A. Holmes, MD ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
   Here’s comes another heaping helping of ultrasound highlights from our winter symposium’s echo extravaganza! In this serving, Dr. Mindy Lipsitz, MD shares some pearls about the suprasternal notch view to assess for trauma, coarctation, aortic root regurgitation, and aortic aneurysm.  Mindy Lipsitz, MD Ultrasound FellowBrigham and Women’s HospitalBoston, MA   Edited and Posted by Jeffrey A. Holmes, MD ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
   Here’s comes another heaping helping of ultrasound highlights from our winter symposium’s echo extravaganza! In this serving, Dr. Mindy Lipsitz, MD shares some pearls about the suprasternal notch view to assess for trauma, coarctation, aortic root regurgitation, and aortic aneurysm.  Mindy Lipsitz, MD Ultrasound FellowBrigham and Women’s HospitalBoston, MA   Edited and Posted by Jeffrey A. Holmes, MD ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
   When you're intubating a patient, twiddling your thumbs, and waiting for your induction/paralytic meds to work, do you ever ask yourself "hmm, should I be bagging this patient?"In this podcast we talk about that very question and the new data from the PREVENT trial.Check out the Podcast by clicking here.Casey JD et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med 2019 Feb 28; 380 (9): 811-821. [Pubmed} ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
   Here’s comes another heaping helping of ultrasound highlights from our winter symposium’s echo extravaganza! In this serving, Dr. Heidi Kimberly teaches us how to identify and characterize the 5 E’s of echocardiography: effusion, ejection fraction, equality of the right and left ventricle, exit (aortic root) and entrance (IVC).   Heidi Kimberly, MD Director of Emergency UltrasoundDepartment of Emergency MedicineBrigham and Women’s HospitalBoston, MA@sonocurious   Edited and Posted by Jeffrey A. Holmes, MD ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
In this blog post we talk ear infections, or Acute Otitis Media (AOM) - a common disease commonly diagnosed... and probably commonly done ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
Which central venous catheter (CVC) is best for our patients? Is it the internal jugular (IJ), subclavian, or femoral? We all have our go- ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
  https://commons.wikimedia.org/wiki/File:Apical_4_chamber_view.png ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
   We apologize that it has been so long since our last blog post . . . we were busy preparing for our annual Winter Symposium. What a fantastic year it was! It included an amazing point of care echocardiography extravaganza by the course’s ultrasound faculty. We covered core content, the 5 E’s of echocardiography, mastering the suprasternal notch, unlocking the apical four chamber view and tricuspid annular plane systolic excursion … phew! We are excited to roll out this content to you over the coming weeks, starting with Dr. Kring’s core content on point of care echocardiography.  Randy Kring, MD Ultrasound Fellow, Department of Emergency MedicineMaine Medical Center, Portland Maine  @EMRMK  ..read more
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 
    THE CASE A 25 year old female presents as a trauma activation after a motor vehicle accident. EMS reports the patient was the belted passenger of a motor vehicle which sustained a passenger side impact versus a tree at 25 mph. The airbags did not deploy, the patient did not lose consciousness, and she did not self extricate. Initial vitals were HR 100, BP of 126/80, RR 22, and SpO2 96% on room air. The patient is complaining of right arm pain and is noted to have a grossly deformed and open right distal forearm fracture. WHAT’S YOUR NEXT MOVE?In the chaos of the critical care bay you force yourself to march through ATLS. The patient’s primary survey is unremarkable - her airway is patent, breath sounds are equal bilaterally, she has strong femoral pulses and no external evidence of hemorrhage. Repeat vitals are HR 105, BP 130/74, RR 20, SpO2 97% on room air. GCS is 15. The secondary survey doesn’t give you any big surprises. You, of course, note the open right distal forearm fracture. The patient has a very minimal amount of diffuse abdominal tenderness with no external evidence of injury. The secondary survey is otherwise unremarkable. Concerned about the patient’s diffuse abdominal tenderness and tachycardia, you decide to do a FAST exam … What is the FAST exam?We know this ultrasound study well. The FAST exam, or Focused Assessment with Sonography in Trauma, is one of the most common applications of point of care ultrasound in the Emergency Department. The goal of the FAST exam is to detect free fluid in the abdomen, typically hemoperitoneum in the unstable trauma patient. The “extended” (E)-FAST exam also looks for pneumothorax, pleural effusion and pericardial fluid. The EFAST exam can quickly evaluate the unstable trauma patient and direct emergent management of hemoperitoneum, hemopericardium, hemothorax, and pneumothorax.[1]To evaluate for free intra-abdominal, pleural and pericardial fluid, the following views are obtained using the curvilinear probe. Free fluid characteristically has sharp edges and will dive between structures, as seen in the clips below.    Right Upper Quadrant Look for free fluid in Morison’s pouch between the liver and kidney, around the inferior liver tip, around the inferior pole of the kidney, and between the liver and the diaphragm. Then visualize the diaphragm and spine; the spine will be visible above the diaphragm only if pleural fluid is present.Right upper quadrant ultrasound with no free fluidRight Upper Quadrant Ultrasound with free fluid in the hepatorenal space Right upper quadrant ultrasound with pleural effusion visualized in the right chest and a positive “spine sign”Left Upper QuadrantLook for free fluid between the spleen and kidney, inferior aspect of the spleen, and between the spleen and the diaphragm. Then visualize the diaphragm and spine; the spine will be visible above the diaphragm only if pleural fluid is present.Left upper quadrant ultrasound with no free fluid visualizedLeft upper quadrant ultrasound with free fluid at the inferior aspect of the spleen extending into the splenorenal space SuprapubicLook for free fluid adjacent to the bladder. It is essential to fan through the entirety of the bladder in a transverse and longitudinal axis.Suprapubic ultrasound through the bladder in transverse orientation with no free fluid visualizedSuprapubic ultrasound through the bladder in longitudinal orientation with free fluid visualized deep to the bladderEvaluate for Pericardial EffusionSubxiphoid: The curvilinear probe is placed inferior to the xiphoid process, angled towards the patient’s left shoulder with the probe flattened to provide a view into the chest. The hyperechoic pericardium is visualized; pericardial effusion will appear as a hypoechoic line between the pericardium and the myocardium.Subxiphoid ultrasound of the heart with no pericardial effusion seenSubxiphoid ultrasound of the heart showing pericardial effusionParasternal: If a subxiphoid view does not provide an adequate view, a parasternal view can be obtained using the phased array probe. Place the probe just to the left of the sternum and slide up and down until you visualize the heart between the ribs.Parasternal long axis ultrasound of the heart with no pericardial effusion seenParasternal long axis ultrasound of the heart showing pericardial effusion To evaluate for pneumothorax, place the curvilinear or linear probe in a longitudinal orientation along the anterior chest wall. Visualize the pleura between rib shadows. Absence of pleural sliding--the “shimmering” or “ants marching” appearance - is characteristic of a pneumothorax.Curvilinear probe on the anterior chest with lung sliding seenLinear probe on the anterior chest with no lung sliding seen, characteristic of pneumothorax  BAck to the case . . . You quickly perform an EFAST on your patient, with the following images obtained below.Right Upper Quadrant Interpretation: No free fluid in the RUQ abdomen or chestLeft Upper Quadrant Interpretation: No free fluid in the chest… but what’s that next to the spleen? Suprapubic Interpretation: No free fluid in the pelvis; uterus is seen at the end of the clipParasternal Long Axis View of the Heart Interpretation: No pericardial effusion Right Anterior Chest Interpretation: No pneumothoraxLeft Anterior Chest Interpretation: No pneumothorax What’s the deal with that LUQ view? Is that a splenic laceration?There is a thick walled, heterogeneous filled structure in the anterior field of the LUQ view which does not persist with posterior fanning. This is characteristic of the stomach and its gastric contents - NOT a splenic laceration! Case ResolutionBased on the mechanism of injury, patient’s diffuse abdominal tenderness, and distracting injury, you ordered a CT scan of the patient’s chest, abdomen, and pelvis to assess for intrathoracic and intra-abdominal injury.  This revealed no evidence of acute traumatic injury in the chest, abdomen, or pelvis.  The stomach was, of course, visualized on CT with a similar appearance to what you saw on your bedside ultrasound:Left upper quadrant ultrasound with stomach and gastric contents visualized next to the spleen  CT of the abdomen and pelvis in coronal plane showing the stomach filled with gastric contents adjacent to the spleenanOther EFAST Fake-Out In addition to visualization of gastric contents in the LUQ, there is another common FAST exam finding that can be easily confused with a positive exam: the double line sign.The double line sign refers to the appearance of a perinephric fat pad (especially in the RUQ), which can easily be misinterpreted as free fluid in Morison’s pouch. Both perinephric fat and free fluid will appear as hypoechoic structures separating fascial planes. However, only a perinephric fat pad will have hyperechoic lines both superficial and deep to the hypoechoic structure - hence the double line sign. These double lines are fascial planes that are visible because of perinephric fat. The double line sign is present in at least 30% of normal exams. There doesn’t appear to be a correlation with BMI, although age does seem to increase the incidence.[2,3]In contrast, when free intraperitoneal fluid is present, only one echogenic line will be visible bounding the fluid. Pathologic free fluid does not highlight fascial planes, unlike perinephric fat.  Compare the two clips below: Right upper quadrant view of the FAST exam showing the double line sign, indicative of perinephric fat between the liver and kidneyRight upper quadrant view of the FAST exam with free fluid seen between the liver and the kidney; no double line sign is seen  This case demonstrates how tricky the EFAST exam can be. In the stressful situation of managing an acute trauma patient, take the time to obtain adequate views as described above. Remember that free fluid characteristically has sharp edges and will dive between structures; it does NOT have smooth edges and walls like physiologic structures (such as vasculature). Be aware of the double line sign and appearance of the stomach on ultrasound so that you don’t call false positives. Ultimately remember that the EFAST exam is a rule-in test, not a rule-out test - it can rule in free fluid and pneumothorax, but a negative EFAST exam doesn’t rule out injury. If you are concerned about an intrathoracic or intra-abdominal injury in a trauma patient in spite of a negative EFAST exam, proceed to comprehensive imaging with CT!Written by Evan Gill, MD & Randy Kring, MDEdited and Posted by Jeffrey A. Holmes, MDReferences:1. The American Institute For Ultrasound In Medicine. (2015). Focused Assessment With Sonography in Trauma (FAST) Examination. Retrieved from https://www.aium.org/resources/guidelines/fast.pdf2. Patwa, A.S. et al.Prevalence of the “Double-Line” Sign When Performing Focused Assessment With Sonography For Trauma Exams. Intern Emerg Med. 2015 Sep;10(6):721-4. [ ..read more

Read for later

Articles marked as Favorite are saved for later viewing.
close
  • Show original
  • .
  • Share
  • .
  • Favorite
  • .
  • Email
  • .
  • Add Tags 

Separate tags by commas
To access this feature, please upgrade your account.
Start your free month
Free Preview