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My buddies, Rory Spiegel and Phillipe Rola taped an amazing conversation about the advanced uses of ultrasound to assess volume/fluid status. I think you will find it as interesting as I did.

Links of Interest

* Portal Veins & Pocus

* A physiologist/intensivist responds

* And more from Phillipe

* Marik has a whole bunch of recent posts on the evils of fluid overload

Now on to the Wee...

You Need to Round on Them

Pulm Toilet

Cuff Pressure

Vent Adjustments

Analgesia and Sedation

Eye Care

 

FEN

Urine Output

Maintenance Fluids

Repeat Labs

Repletions

 

Meds

The 2nd Dose of Antibiotics

* Crit Care Med 2017;45:956

Insulin for IDDM

Medication Reconciliation

anti-coagulants, anti-platelets, rejection meds, endocrine meds, statins,

Update--Venous Thromboembolism Prophylaxis

Glaring omission in the audio. Thanks for reminding me, Maarten!

Alarms

Ventilator Alarms

Pump Alarms

 

 

This post is part of the bleeding edge series--you have been warned!

What you'll hear....

Two Phenotypes of Critical COPDers

* Severe Bronchospastic Crisis

* Hypercapneic Encephalopathy

This episode primarily talks about #2

The New Reflex Actions for Coma/AMS

* Check Fingerstick

* Look at the Pupils/Resp Rate

* Look for Stigmata of Seizure/Recently Completed Seizure

* Get a VBG

The Controlled Burn for Hypercapneic Encephalopathy in COPD

This is the bleeding edge part. I am super-curious to hear what you think. Place your comments below.

Articles to Read

* Resp Med 2011;105:1109

Now on to the Podcast...

After Podcast 211 with Anders Ericsson, I promised my thoughts on deliberate practice and expertise...

But first, something sad:

Bob Wears has died

Read a wonderful obituary

Reality behind 10,000

let's think about that... Innate non-physical talent doesn't really matter that much.  Can't alter your height, but can alter your brain

Driving a car for 10000 hours doesn't make you an expert driver. We do exactly zero hours of deliberate practice. We have no coach.

Procedures

My fellows filming themselves

Microskill breakdown

Why Purposeful much less deliberate practice is tough in Emergency Medicine

Experts vs. Experts @ Teaching

EM & Crit Care Lacks Feedback

Mental Representations/Mental Models

OODA Loops

experts have very good memory of what has happened

verbalize thinking

sob low sat tachypenic

pt looks bad, start thinking airway

SCAPE, mental status good, pt will respond to BIPAP

CHF

Surgical Scripts Book Abernathy & Hamm

Mental Models Article from Michael Simmons

Shadowboxing

watch stimuli

commit to a course

listen to the expert

Thought Experiment on Computer Based Ratings

Are Experts Actually Experts?

Name Badge Believers

How to Create Purposeful/Deliberate

right time of day

plenty of sleep

deliberate practice is deep work

patience 15-20 minutes, not 4-5 hours at least at first

need a coach or if you can't find an expert performer and ask them how they got good

good teacher builds representations

Mental practice

cric training

given videos

smacc airway workshop

no place your hands here

The Diamond Age

[easyazon_image align="none" height="160" identifier="0553380966" locale="US" src="http://emcrit.org/wp-content/uploads/2017/11/51lC2BbJe3lL.SL160.jpg" tag="emcrit-20" width="100"]

a [easyazon_link identifier="0553380966" locale="US" tag="emcrit-20"]book by Neil Stephenson[/easyazon_link]

We need a primer

Update:

* A fantastic review of Deliberate Practice

Now on to the Podcast...

So I recently did an interview with the Curbsiders, an IM podcast, on why EM and IM sometimes have conflicts. It was a ton of fun and may be worth a listen. Here is the episode:

The Curbsiders with Guest, EMCrit

 

Find Out What this Diagram Means

EEMCrit Conference Resident Competition

Speak at the EEMCrit Conference and win a spot at the EEM Conference in May

EEMCrit Blast Competition

Now on to the Wee...

Mike Lauria set up an interview with Dr. K. Anders Ericsson, first author of [easyazon_link identifier="0544947223" locale="US" tag="emcrit-20"]Peak: Secrets from the New Science of Expertise[/easyazon_link]. Dr. Ericsson is a brilliant cognitive psychologist, currently at the Florida State. He has dedicated his career to studying the science of expertise and performance. He was incredibly generous with his time, to the tune of a 2-hour interview. In the podcast below, I excerpted some of the most interesting pieces, but it was all great. If you want to listen to the unedited, full interview I have placed a link below.

[easyazon_image align="none" height="500" identifier="0544947223" locale="US" src="http://emcrit.org/wp-content/uploads/2017/10/415liK8nJLL.jpg" tag="emcrit-20" width="332"]

10,000 Hour Rule Debunked

* from Salon

How to Deliberately Practice in Diagnostic Medicine

* Get recordings of patient presentations, get people to commit, listen to what an expert would do, and then show what happened.

Full Unedited Interview

* ~ 2 hours of Dr. Ericsson

Want More?

* Art of Charm Interview with Dr. Ericsson was Amazing!

* Brian Johnson's Summary

* The Seductive Path of Good Enough

* Deliberate Practice from Farnam Street

* The Academic Paper on Deliberate_Practice_and_the Acquisition of Expertise by Dr. Ericsson

* Pondering EM did a Two-Parter on Deliberate Practice (Part 1 & Part 2)

* The Path to Insanity

Now on to the Interview...

For Show Notes and To Leave Comments, Got to EMCrit.org/210

Now here is Part 2

Today, we talk about arterial lines. I love arterial lines: monitoring, true MAPs, easy blood draw, easy blood gases, fluid status--what's not to love.

This turned into a 2-parter. Part 1 covers radial art lines

Here is Arterial Lines - Part 2

covers everything else below

The (Essentials of EM)Crit Conference

go to EMCritConference.com

use the promo code "emcrit" when you sign up

Part 1 Covers:

Radial Arterial Lines

Peripheral vs. Central Arterial Lines

Sterility

Here is a systematic review of most of the literature

[cite]24413576[/cite]

My take on it is, use sterile gloves, mask, chlorhexidine prep, and if you can grab a fenestrated drape or some OR towels.

Technique

* Kit (The one I use is Arrow RA-04020)

* Ultrasound

* Threading

* How to Save it

* Allen Test

Securing

Tegaderm alone is not enough. I suture, but I really wish we had arterial line stat-locks

I always loop around the thumb and secure with tape outside of the tegaderm--I hate replacing pulled out art lines

Central vs. Peripheral Arterial Pressures

[cite]28523028[/cite]

Part 2 Covers:

Femoral

Sterility-Full Sterile

unless you are going for speed or the Dirty Double

Technique

Use Ultrasound

Find the Common Femoral Artery

 

Use of a central line kit?--No!

Back of wire? Check, but yes!

Axillary

Need Ultrasound

Brachial

Is it safe?

Dorsalis Pedis

https://www.ncbi.nlm.nih.gov/pubmed/28523028

The Arterial Line Set-Up

How to set up an art line pressure transducer

You do not need to wait for crash arterial lines

Heparin Flush

Pimping Ammunition - Where is that Catheter

sent by Intensivist, Mark Dunn

Central vs. Distal Arterial Discrepancies

* Risk Factors Involved in Central-to-Radial Arterial Pressure Gradient During Cardiac Surgery PMID: 26599795

* Pulmcrit with far more on this

Now on to the podcast (and Remember: Here is Part 2)...

Please Send me your ideas on how to...

Artificiality of Dissemination

* Is email the best forum?

* Get people to actually read the emails you send re: departmental protocols, changes, ideas, etc.

* Do you track?

Referencing Reference

* How do you create a reference site?

* What nitty-gritty details?

* Is it password protected? Does everyone have a unique login?

* How do you sort/create search--what pages, tags, categories, long tables of contents, etc.

* How do you handle orientation into your new unit/department

Old Dogs, New Skills

How do you teach new skills

* Meetings

* Videos

* Screencasts

Post thoughts on Reddit here:

REDDIT Post for this Wee

Now on to the Wee...

A few years ago, I put out a podcast on Getting Things Done--people seemed to really like discussing this topic. I am giving a lecture on this subject this week. It has gotten me thinking about some of the higher level aspects of GTD and I thought I would share some of them with you.

Deciding on Opportunities

Present you vs. future you

Petrie Triangle

Matt Davella's Yes? Checklist

Here's mine if you want to use or edit it for yourself... Should I Say Yes?

Does it excite the hell out of me?

Would I do this regardless of money?

What will I have to give up to do this?

Will it contribute beyond myself?

Will I grow from this experience?

Will I regret not doing it?

Time Tracking/Forecasting

Opportunity Cost

Deciding on Goals

Deep Work

[easyazon_image align="none" height="110" identifier="1455586692" locale="US" src="http://emcrit.org/wp-content/uploads/2017/10/51kzUUHhMTL.SL110.jpg" tag="emcrit-20" width="73"]

Time Blocking

Pomodoro technique

creator's website

Getting Tactical re: Email

* Put the call to action up top

* Preempt the back-and-forths

* doodle.com

* Close the loop beforehand

* Ask one ?, make it easy, and make sure it is not web-searchable/already answered

Resus Fellowship

Click Here for More Info on the Stony Brook Resus Fellowship

Now on to the Podcast...