EMCrit FOAM Feed

Anatol Rapoport’s Rules: How to compose a successful critical commentary by Daniel Dennett

* You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.

* You should list any points of agreement (especially if they are not matters of general or widespread agreement).

* You should mention anything you have learned from your target.

* Only then are you permitted to say so much as a word of rebuttal or criticism.

Step 1 is analagous to steel-manning, aka the principle of charity. This is to avoid the act of straw-manning.

from the amazing book, [easyazon_link identifier="0393348784" locale="US" tag="emcrit-20"]Intuition Pumps and Other Tools for Thinking[/easyazon_link]

Paul Graham's Hierarchy of Disagreement

for more on this

What would it take to Change Your Mind?

Ask your subject, what would need to change for them to change their belief?

More questions to ask yourself

Grice's Maxims

* 4 Maxims that can serve as a guide-map to conversation and argument

Anti-Good Argumentation

* Some tips for evil debate

Logical Fallacies

* Avoiding Logical Fallacies

* More on logical fallacies

* How to craft a good argument

The Book to Buy

[easyazon_image align="none" height="66" identifier="1615192255" locale="US" src="http://emcrit.org/wp-content/uploads/2016/08/61jZofXRoUL.SL75.jpg" tag="emcrit-20" width="75"]

[easyazon_link identifier="1615192255" locale="US" tag="emcrit-20"]An Illustrated Book of Bad Arguments[/easyazon_link]

Ten Commandments of Rational Debate

by trolling2day1

The ones I see infecting FOAM debate again and again

Three logical fallacies, two seen universally and the other unique to medicine. The former two are the status quo bias and the bad-bayesian bias and the latter is Benefit/Harm Evidence Equalization.

Status Quo Bias

Thinking b/c we do things a certain way, there is evidence behind this way

Bad-Bayesian Bias

See Rich Carden's discussion of Baye

Benefit/Harm Evidence Equalization

Harm requires markedly less evidence of lower quality than benefit

An Example

responses to the Wee on the modification of scalper-finger-bougie technique

Today, I am joined by my friend, Mike Lauria, to interview Gary Klein, PhD. Dr. Klein is a masterful cognitive psychologist. He is known for many groundbreaking works, including: the Recognition-Primed Decision (RPD) model to describe how people actually make decisions in natural settings; a Data/Frame model of sensemaking; a Management by Discovery model of planning to handle wicked problems; and a Triple-Path model of insight. He has also developed several research and application methods: The Critical Decision method and Knowledge Audit for doing cognitive task analysis; the PreMortem method of risk assessment; the ShadowBox method for training cognitive skills. He was instrumental in founding the field of Naturalistic Decision Making.

The Books

[easyazon_link identifier="0262611465" locale="US" tag="emcrit-20"]Sources of Power[/easyazon_link]

[easyazon_image align="none" height="160" identifier="0262611465" locale="US" src="http://emcrit.org/wp-content/uploads/2016/08/41VfJMqMiCL.SL160.jpg" tag="emcrit-20" width="102"]

This is the one that got Mike and I started as Klein Fanboys

[easyazon_link identifier="0262516721" locale="US" tag="emcrit-20"]Streetlights and Shadows[/easyazon_link]

[easyazon_image align="none" height="160" identifier="0262516721" locale="US" src="http://emcrit.org/wp-content/uploads/2016/08/414lx3VWCL.SL160.jpg" tag="emcrit-20" width="108"]

The absolute best compilation of Dr. Klein's decision-making concepts that are directly applicable to medicine

[easyazon_link identifier="1610393821" locale="US" tag="emcrit-20"]Seeing What Others Don't[/easyazon_link]

[easyazon_image align="none" height="160" identifier="1610393821" locale="US" src="http://emcrit.org/wp-content/uploads/2016/08/51MsCqgkOL.SL160.jpg" tag="emcrit-20" width="107"]

Next up on my reading list

Recognition Primed Decisionmaking

Wikipedia Link for RPD

Sites and Links

* Dr. Klein's Company

* Shadowbox Training

Articles Mentioned in the Show

* Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009 Sep;64(6):515-26.

* Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches. Journal of Cognitive Engineering and Decision Making

Additional Related Stuff

* Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.

* Effects of reflective practice on the accuracy of medical diagnoses.  Going fast might not induce more error, it's about experience and if you have the patterns to recognize:

* Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Slowing down doesn't help.  Slow is just slow. Smooth is FAST, and smooth is about economy of cognitive resources and movements

*

So I've been teaching my version of the scalpel-finger-bougie cric method for a few years now. I've used it on actual patient cricothyrotomies with great success. If you are not familiar with the way I teach, you can see a ton of the EMCrit cric resources here. One component of the technique that I'd been teaching is a secondary confirmation of intratracheal placement via obtaining hold-up with the bougie somewhere in the right bronchial tree. A set of comments brought up the possibility that with enough effort, a false hold-up could be obtained:

@ketaminh @emcrit @the_TOTAL_EM @cliffreid it is possible to unintentionally intubate the right atria when trying to cric, with min effort

— Jason Bowman (@texprehospital) July 4, 2016

Well, that sounds less than good. So first I wrote to EM anatomy guru, Andy Neill.

From the most recent Gray’s anatomy Textbook (the big bible at the mo)

"The pretracheal layer of the deep cervical fascia is very thin. It provides fascial sheaths for the thyroid gland, larynx, pharynx, trachea, oesophagus and the infrahyoid strap muscles. Superiorly, it is attached to the hyoid bone; inferiorly, it continues into the superior mediastinum along the great vessels and merges with the fibrous pericardium;”

and

"The retrovisceral space [this would be if you got your bougie between post trachea and oesophagus] is continuous superiorly with the retropharyngeal space. It is situated between the posterior wall of the oesophagus and the prevertebral fascia. Inferiorly, the retrovisceral space extends into the superior mediastinum. Should the prevertebral fascia merge with the connective tissue on the posterior surface of the oesophagus – usually at the level of the fourth thoracic vertebra – the retrovisceral space then has a distinct inferior boundary."

The suggestion here is that there’s a fascial plane from the pretacheal fascial space to the sup mediastinum but closed at that point and you would have to penetrate the fibrous pericardium with bougie to access the pericardial space (which i suppose you could do if you were really enthusiastic with your bougie!). You’d have to push even harder to actually penetrate the heart itself. The retrovisceal space has a clear boundary at T4 posteriorly which is still above the heart and more importantly much more posterior.

Bottom line the communicating fascial planes won’t get you further than the superior mediastinum as far as i can work out.

Though if you sharpened your bougie to a fine a point or used a chest drain trocar then i’m sure you could make it to the heart ;-)

Well, that sounds less than good because it still means if you are willing (unaware) and dissect through some tissue planes, you can definitely get holdup on the pericardium. But could this really be done easily? To find out, I reached out to my friend, George Kovacs. George tested this theory with the help of his amazing EM residents. You can see the results below.

TLDW: It is possible, in the hands of adrenalized novices, to get a false hold-up sign with the bougie during cricothyrotomy. I no longer recommend this secondary confirmation.

Minh, before you comment, this has nothing to do with the hold-up sign during orotracheal intubation.

Now on to the Wee...

So I love awake intubation. I've done a ton of previous stuff on the topic of Awake Intubation. My friend, George Kovacs, introduced me to some new gear at one of the AirwayCam course. This changed the way I performed awake intubation--it also made it MUCH faster. So here is how I currently perform awake intubation.

* If you want to see a full lecture by George, go to Podcast 194

Dissociated Awake is what I used to do when I had a time crunch (Pt needs to be tubed now)

EAT Awake is what I do now

* Suck & Pad

* Topicalize

* Analgese

* Intubate

* Sedate

EZ-Atomizer

use the EZ Atomizer to topicalize everything but through-the-cords

You must use 4% lidocaine. Give 10-14 mls (may want to dilute to 3% in patients with low body weight or liver failure)

Flow Rate is 8 lpm on oxygen or air

Topical Lidocaine Lollipop

As high a concentration as you can get

MADgic Device

Plus/Minus Sedation/Analgesia

 

You can never see too many demonstrations of the technique, so here is another video:

George Kovacs on Airway Topicalization

Updates

RCT of 10% spray vs. Nebs--10% spray much better (Chest 2020;157(1):198)

Now on to the Wee...

I laid out my thoughts on the management of hyponatremia way back in Podcast 39. Josh has weighed in here on the dDAVP clamp as well. I'd been continuing my readings on this matter, especially with some great posts from the renal fellow network (below). Then, fortuitously, I was approached by Nand Wadhwa, one of our amazing nephrologists at Stony Brook. He wanted to partner with my unit to create a euvolemic hyponatremia protocol. So in this episode, we'll discuss the use and basis of the new Euvolemic Hyponatremia Guideline.

The Protocol

Included Patients

* Euvolemic or Hypovolemic

* Na <=125 (we changed this to <=120)

Evidence for dDAVP Clamp with 3%

* Am J Kidney Dis. 2013;61(4):571-578

* Clin J Am Soc Nephrol 9: 229–237, 2014

from this post

http://renalfellow.blogspot.com/2014/10/severe-chronic-hyponatremia_20.html

Clin J Am Soc Nephrol 2007;2:1110

Modified Edelman Equation

from Androgue, Madias 2012

Video on Why Androgue Madias Equation doesn't work and how to use the Edelman Equation from Hashim Mohmod

Causes of Hyponatremia

See this Deranged Physiology Page and the LitFL Page

The Renal Fellow Network Hyponatremia Series by Hashim Mohmand

* Part 1

* Part 2

* Part 3

* Part 4

* Part 5

Key Points from the Series

Severe hyponatremia is multifactorial

Sood et al.

Three issues that will screw your plans up:

* Subclinical Volume Depletion: Because we suck at assessing this

* Solute Depletion Hyponatremia: For instance,  "Tea and Toast Diet " hyponatremia and "Beer Potomania."

* Hypokalemia Repletion [case report]

* Read a Review Article by Dr. Mohmand on these issues

Review Articles

* Crit Care Hyponatremia Review 2013

* Androgue Madias Review

Peripheral 3% Hypertonic Saline is Safe

* Here is just some of the evidence

Things to think About

In the LaMW: Ox Kills podcast, I discussed preoxygenation strategies. Sam Ghali had some questions; this wee has the answers.

Groombridge et al.

NRB @ 15 lpm  = 52.6%

NRB @ 15 lpm + NC @ 5 lpm = 57.1%

Max with anesthesia circuit

Hayes-Bradley et al.

http://www.annemergmed.com/article/S0196-0644(15)01500-0/abstract

Here are their numbers (they also simulated air leaks in this study)

NRB @ 15 lpm alone = 52% ETO2

NRB @ 15 lpm + NC @ 10 lpm = 67%

BVM = 79%

BVM with Mask Leak: BVM markedly improved with NC

Russell_et_al.

Nasal cannula improved ETO2 when mask leak was created

My friend, Chris Hicks, is an emergency physician and trauma team leader in Toronto, Canada. His niche and research work revolves around human factors, team performance, and stress management for individuals and teams. We brought him down to give a grand rounds lecture; this is a recording of that lecture.

The Slides

* Hicks-Stony Brook GR 2016

Videos from the Talk

Scene from the amazing movie, The Hurt Locker

Rhee performing Surgical Airway

https://vimeo.com/174238414

Trauma Sim

Trauma Sim Movement Tracking

Now on to the Lecture...

John Hinds coined the term #resusWANKER at his amazing SMACC lecture on thoracotomy. I created this lecture on resusWANKERS in dedication to John and gave it at the Teaching Course in NYC. I gave it a second time at the Royal College of Emergency Medicine meeting in Manchester. This recording came from the third and final iteration in Glasgow, Scotland. I'd love to hear what you think--please comment below:

the seven resusWANKERS:

1. Wrong-but-Strongers (Dunning Kruger Effects)

* J Pers Soc Psychol 1999;77(6):1121

* Are We All Less Risky and More Skillful than our Fellow Drivers? (DOI: 10.1016/0001-6918(81)90005-6)

* Dunning When Knowledge Knows No Bounds- Self-Perceived Expertise Predicts Claims of Impossible Knowledge

2. Name Badge Believers (Specialty Name Bias)

3. Water Torturers (Decision Fatigue)

* PNAS 108(17):6889

4. EKG Thrusters (Slips/Sterile Cockpit)

* Intraoperative Noise Increases Perceived Task Load and Fatigue in Anesthesiology Residents: A Simulation-Based Study (Anesthesia and Analgesia 2016, 122 (2): 512-25)

* Noise Levels in Surgical ICUs Are Consistently Above Recommended Standards. (DOI: 10.1097/CCM.0000000000001378)

* Task Interruptions and Error Rate

* Slips increase with practice/expertise

* ECGS are a source of task interruption

5. Leadership Encroachers

6. Slothful and Avoidant

7. Just Plain Dicks

Now watch the lecture...

Three years ago (holy crap!), I put out the first version of the EMCrit RSI Checklist in this Podcast (92). Vahe Ender (@calldaburd) inspired me to reduce it to a business card/ID card sized version. I also simplified, clarified, and improved every aspect of the checklist. So here is the 2.0 version. The original is still great, it may just take a few seconds longer to use the old one. This is a no bullshit, less than 60 second version that has been field-tested 100's of times.

The EMCrit RSI Checklist v 2.0

Printable Version of EMCrit RSI Checklist

CricCon2

EMCrit Remix of the STC Failed Airway Algorithm

Printable Version of the STC Failed Airway Algo 2.0

Here is the Failed Airway Algo I see many centers use in lieu of the STC Algo

Attribution: Doktor Schnabel from the GomerBlog

Syringe Labels

* RACC Syringe Labels as of 2015-10-21 (Right Click and Choose Save-as)

Airway Bag (Sydney HEMS DumpKit)

Go to the Resus.cc site to see our version

Want to hear an actual use of the checklist with nurse calling and doc responding?

I'll be putting it up as a wee this week; sorry : (

Some Literature on Checklists for Crit Care Airway

* Resuscitationists Airway Checklists

Additional Stuff

* Article on IVC to predict hemo decompensation after intubation

* Evidence for Intubation Checklists (Ann Emerg Med. 2016 Mar;67(3):389-95)

Here is the checklist sheet and debrief form we will actually be using in the RACC

* Airway Debrief 20160508

Now on to the Vodcast...

My opening talk at SMACCdub was on meditation: vipassana and stoic negative contemplation.

This wee will make more sense if you watch that lecture first

* Kettlebells for the Brain

It will be available in the next few months. Hopefully this wee will tide you over.

Read

* Book: The Mindful Geek: Secular Meditation for Smart Skeptics

* Book: Waking Up: A Guide to Spirituality Without Religion

Watch

* Michael Taft at Google

Science

Scientific American Article on the Mind of a Meditator

Muse Headband

* Muse: The Brain Sensing Headband - Black

Headspace App

Online or for Phones

Now on to the Wee...