Brian Clyne

Management of the difficult airway: alternative airway techniques and adjuncts

Rapid-sequence intubation using conventional laryngoscopic technique remains the standard of airway management in emergency medicine and continues to have a success rate of approximately 98%. Preparation and proper intubation technique must be optimized at the initial attempt using direct laryngoscopy. Failure causes multiple repeated attempts, leading to a failed airway. Each repeated attempt increases the likelihood of bleeding, oral, pharyngeal, and laryngeal edema, and malposition, causing decreased visualization of the glottic opening, equipment failure, and hypoxia. Preparation must be an ongoing process. Faulty suction, no oxygen source, choice of the wrong laryngoscopic blade or ETT, poor light source, or misplaced equipment can domino into mechanical failure. Intubation equipment stations must be inventoried constantly, organized, and kept simple in their layout to decrease confusion during selection. Medication for sedation and paralysis should be readily available and not kept distant from the intubation station in a medication-dispensing unit that would require time for acquisition. Proper positioning of the patient remains paramount for alignment of the oral, pharyngeal, and laryngeal axis to provide optimal visualization of the vocal cords. Proper technique during insertion of the laryngoscope blade in the oral cavity for displacement of the tongue must be ensured. Without proper technique, even with proper positioning, the glottic opening cannot be visualized. Laryngeal pressure to maneuver the larynx into position should be exerted initially by the laryngoscopists right hand and, when in view, maintained by an assistant to free the laryngoscopists hand for ETT insertion. With preparation and proper technique, the first attempt is the best attempt, and the vicious cycle of multiple attempts and complications will be averted.

Aluminum foreign bodies: do they show up on x-ray?

The objective of this study is to evaluate the utility of radiographs in the detection of aluminum foreign bodies (FB). Aluminum can tabs were placed at the upper esophagus/posterior pharyngeal area in ten randomly selected cadavers. Anterior–posterior (AP) and lateral (LAT) radiographies were performed before and after placement. Twenty sets of randomly ordered radiographs were assessed by two blinded radiologists for the presence of radio-opaque FB. For any positive reading on an AP or a LAT radiograph, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for radiologist A were 80, 90, 89, and 82%, respectively, and for radiologist B were 90, 100, 100, and 91%, respectively. These values were also calculated using only AP and LAT views. Aluminum FB can often be visualized on radiographs. The sensitivity of this method, however, is not adequate to completely rule out their presence. Additional testing in these cases is warranted. Conversely, a high PPV suggests that therapy based on this finding alone is a logical choice.

Foundations for a Novel Emergency Medicine Subspecialty: Sex, Gender, and Women's Health

Sex and gender affect all aspects of health and disease, including pathophysiology, epidemiology, presentation, treatment, and outcomes. Sex- and gender-specific medicine (SGM) is a rapidly developing field rooted in womens health; however, inclusion of SGM in emergency medicine (EM) is currently lacking. Incorporating principles of sex, gender, and womens health into emergency care and training curricula is an important first step toward establishing a novel subspecialty. EM is an ideal specialty to cultivate this new field because of its broad interdisciplinary nature, increasing numbers of patient visits, and support from academic medical centers to promote expertise in womens health. This article describes methods used to establish a new multidisciplinary training program in sex, gender, and womens health based in a department of EM. Womens health and SGM program initiatives span clinical care, patient education, clinical research, resident and fellow training, and faculty development.

A case of traumatic pneumocephalus.

A 39-year-old male presented to the Emergency Department (ED) with a chief complaint of headache for 3 days. The patient had fallen down a flight of stairs 3 days prior to presentation and had a loss of consciousness. Following the event, he noted clear nasal discharge and a salty taste in the back of his throat that had resolved spontaneously after 24 h. He finally sought medical attention for worsening headaches, intermittent dizziness, and right eye pain. On physical examination, he had a right periorbital contusion without step-off or crepitus. The eye was normal. The patient had no neck stiffness or meningeal

Influence of clinical experience and productivity on emergency medicine faculty teaching scores.

BACKGROUND Commonly cited barriers to effective teaching in emergency medicine include lack of time, competing demands for patient care, and a lack of formal teaching experience. Teaching may be negatively affected by demands for increased clinical productivity, or positively influenced by clinical experience. OBJECTIVE To examine the association between faculty teaching scores and clinical productivity, years of clinical experience, and amount of clinical contact with resident physicians. METHODS We conducted a retrospective, observational study with existing data on full-time faculty at a high-volume, urban emergency medicine residency training program for academic year 2008-2009. Residents rated faculty on 9 domains of teaching, including willingness to teach, enthusiasm for teaching, medical knowledge, preparation, and communication. Clinical productivity data for relative value units per hour and number of patients per hour, years of clinical experience, and annual clinical hours were obtained from existing databases. RESULTS For the 25 core faculty members included in the study, there was no relationship between faculty teaching scores and clinical productivity measures (relative value units per hour: r (2)  =  0.01, P  =  .96, patients per hour: r (2)  =  0.00, P  =  .76), or between teaching scores and total clinical hours with residents (r (2)  =  0.07, P  =  .19). There was a significant negative relationship between years of experience and teaching scores (r (2)  =  0.27, P < .01). CONCLUSIONS Our study demonstrated that teaching scores for core emergency medicine faculty did not correlate with clinical productivity or amount of clinical contact with residents. Teaching scores were inversely related to number of years of clinical experience, with more experienced faculty earning the lowest teaching scores. Further study is necessary to determine if there are clinical measures that identify good educators.

An Agenda for Increasing Grant Funding of Emergency Medicine Education Research

Funding is a perennial challenge for medical education researchers. Through a consensus process, the authors developed a multifaceted agenda for increasing funding of education research in emergency medicine (EM). Priority agenda items include developing resources to increase the competitiveness of medical education research faculty in grant applications, identifying means by which departments may bolster their facultys grant writing success, taking long-term steps to increase the number of grants available to education researchers in the field, and encouraging a shift in cultural attitudes toward education research.

The state of leadership education in US medical schools: results of a national survey

ABSTRACT Over the past two decades, there have been increasing calls for physicians to develop the capabilities to lead health care transformation. Many experts and authors have suggested that leadership education should begin during medical school; however, little information exists regarding the presence or nature of undergraduate medical education leadership curricula in the USA. This study sought to determine the prevalence of formal leadership education in US undergraduate medical schools, as well as the delivery methods and degree of student participation. A web-based survey of medical education deans from US allopathic medical schools (N = 144) was administered from November 2014 to February 2015. The survey included questions on the presence of leadership curricula, delivery format, student participation rates, and forms of recognition. Eighty-eight surveys were completed; the majority (85%) of respondents were associate or assistant deans for medical education. Approximately half (54.5%) of respondents reported leadership curricula within their medical schools. Of those, 34.8% (16/46) were required; 32.6% (15/46) were elective; and 32.6% (15/46) indicated both required and elective components. Of schools with formal leadership curricula (n = 48), the common forms of content delivery were: mentoring programs (65.1%); dual degree programs (54.5%); workshops (48.8%); seminar/lecture series (41.9%); courses (41.9%); or single seminars (18.6%). Nineteen percent of institutions offer longitudinal leadership education throughout medical school. Common forms of recognition for leadership education were: course credit (48.8%); dual degrees (37.2%); certificates of completion (18.6%); and transcript notations (7.0%). This study indicates that formal leadership education exists in more than half of US allopathic medical schools, suggesting it is an educational priority. Program format, student participation, delivery methods, and recognition varied considerably. Further study is needed to identify the optimal content, competencies, and pedagogy for leadership education. Identifying best practices may help guide standards for leadership curricula across UME and fill this educational need.

Creating effective and engaging presentations

Effective presentation skills are vital tools in the clinician educator ’ s toolbox. Today ’ s learners expect more than traditional presentations that often involve speakers reading from cluttered and wordy slides. This article integrates educational theory with practical advice to provide suggestions to improve the three fundamental components of every presentation: the message, the visuals and the delivery.

The Intersection of Gender and Resuscitation Leadership Experience in Emergency Medicine Residents: A Qualitative Study

The objective was to examine emergency medicine (EM) residents’ perceptions of gender as it intersects with resuscitation team dynamics and the experience of acquiring resuscitation leadership skills.