Think pulmonary embolism and you may find it….

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:  “Prospective Multicenter Evaluation of the Pulmonary Embolism Rule-out Criteria.” (J Thromb Haemost 2008;  Kline JA et al.)

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Main Points

  1. Pulmonary Embolism Rule-out Criteria (PERC):
  • age < 50,
  • heart rate < 100 bpm
  • SaO2 < 95%
  • no hemoptysis
  • no estrogen use
  • no surgery/trauma requiring hospitalization within 4 weeks
  • no unilateral leg swelling
  • no prior venous thromboembolism

2) PERC in combination with clinical gestalt for low suspicion of pulmonary embolism (PE) reduces the probability of venous thromboembolism (VTE) to below 2%.


Chest pain is the most common emergency department chief complaint.  The differential diagnosis is vast, and includes high acuity conditions (such as myocardial infarction, aortic aneurysm, and pulmonary embolism) down to low acuity conditions (such as reflux, muscle strain and anxiety.)  Pulmonary embolism is one of the high risk clinical conditions that should not be missed. However, determining which patient should or should not be worked up for pulmonary embolism can be difficult.   Continue reading

Medium ≠ Message

If you read one thing printed on real paper this week, make it this letter (1), followed by this response. (2)

(OK, you don’t actually have to print it on real paper, but know that it is, in fact, available printed on paper in the leading medical education journal. Or you can just point and click. For free.)

The rapid expansion of free, open-access medical edutainment has led us headlong into debate. To sum up the discussion, these two letters to the editor refer to a previously-published article by Mike Mallin, an emergency physician and EM educator in Utah, and colleagues surveying the use by EM residents of asynchronous education resources, which they define as “a student-centered modality of teaching which involves sharing online learning resources and promotes peer-to-peer interactions,” and which includes podcasts, blogs and other online shareable media. (3) Known collectively/colloquially as FOAMed (Free Open-Access Meducation), these resources are now part and parcel of many EM training programs, able to be consumed at one’s own pace, on one’s own time.

Pescatore and colleagues, in their letter to the editor, worry aloud that the messages trumpeted via asynchronous resources are at risk of being interpreted as gospel truth by unsuspecting consumers without critical consideration of their merits. Particularly susceptible to this, they argue, are the most popular of these resources and the most junior of consumers. They cite a discussion about treatment of infant bronchiolitis on an episode of the EM:RAP podcast wherein a popular contributor to that podcast made a treatment recommendation that is not supported by – and may be frankly frowned upon – by national societies in pediatrics (and which, in fact, may have been dangerous). If taken as truth rather than opinion – a real risk when impressionable listeners are swayed by the near-celebrities on popular sites – this may lead to an increase in an arguably unsafe practice. Continue reading

Twitter Tips for EM

Screen Shot 2015-09-02 at 8.30.01 PMIn #emconf (that’s EM Conference!) today, within a talk on social media and medical education, I gave a short beginner’s workshop on using Twitter for professional and educational purposes.  I recommend that you have a Twitter account dedicated to professional networking and education, which you use to engage with other emergency physicians (or professionals in other fields from whom you’d like to learn. I follow surgeons, internists, nurses, education experts–even a rheumatologist or two for good measure!)

Follow Kim Kardashian and tweet your cat pictures from your personal account. Use a separate account for your real professional persona, to follow and interact with ACEP, SAEM, AAEM, EMRA, other EM residencies, researchers, educational sources, and medical colleagues–here and all around the world.

A great place for an overall Twitter introduction is Dr. Joyce Lee’s Twitter SuperUser site.  Check it out, and the links that she provides. (This is a general introduction to the physician on Twitter, not necessarily geared towards academics and medical education.)

Here are links to the handouts provided today. The first includes a list of resources about the Free Open Access Med-ucation movement (FOAM), Continue reading

Lumbar Puncture Part 2: Pearls, Pitfalls, and Troubleshooting

a monthly blog series on procedures

Take your LP skills to Eleven: this is spinal tap!

Last week we discussed the basics of the adult LP. This week we will guide you through some difficult scenarios and their solutions.


troubleshootingYour patient is nervous and squirmy

  • Consider having an assistant hold and position the patient.
  • Steady the shaft of the needle with your non-dominant hand.
  • Talk to the patient. Here are some examples of what you can say prior to the procedure:
    • “I will numb up your back, and that should be the only part that hurts.”
    • “Most of the procedure is just setting up my materials.”
  • During the procedure, the patient cannot see you, which can be anxiety provoking. Describe each step of the procedure in a calm manner. And try to avoid THIS.
  • If necessary, administer an anxiolytic such as a benzodiazepine.

troubleshootingYour patient is very sensitive to pain

  • First, lidocaine!
    • Did you inject enough volume into the deeper structures of the back? As Dr. Whit Fisher mentioned in the comments of the previous post, make sure you gather extra lidocaine (only 5ml in the LP tray). In a sterile fashion, draw up an extra 5-10 ml with the help of an assistant.
    • Note: if trying a new interspace, make sure this area is also anesthetized.
  • Patient still in pain? Consider administration of an analgesic such as an opioid.

Continue reading