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On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at be...

March 27, 2012

Bimanual Laryngoscopy

This is adapted from a comment I left in response to an excellent Broome Docs post on RSI updates

BURP vs burp
I am a much bigger fan of external laryngeal manipulation (ELM) above BURP.

Put simply:

Sellick: pressure on cricoid
BURP: assistant puts backwards-upward-rightward pressure on thyroid cartilage
ELM: laryngoscopist moves around the thyroid cartilage with their right hand, in any direction

As mentioned in the Broome Docs post, the goal of Sellick is to prevent gastric insufflation and passive regurgitation, while BURP and ELM are laryngoscopy aides; as also discussed at Broome Docs, Sellick is likely: useless for it's intended goal; often worsens your glottic view; and, may impair tube delivery. Therefore, I've taken it off my radar as there's enough more important things for us all to think about during airway management.

I think of BURP as a "good guess" at the optimal movement (I would guess about 60% accurate).

The technique I learned from Reuben Strayer is to have the assistant put their hand on the thyroid cartilage; the laryngoscopist then moves assistant's hand AND therefore the thyroid cartilage in any/every direction until the view is optimized; the laryngoscopist can then remove their hand, leaving the assistant holding the thyroid in the correct place.

Reuben discusses this (briefly) in his excellent airway lecture just before the 27 min mark.

One note on nomenclature:
Some people have called this "bimanual laryngoscopy" (including Levitan; reference in the comments below); others use that term to describe the laryngoscopist moving the patient's head during laryngoscopy.

I don't know if I'm right or not, but I think of BOTH of those maneuvers (ELM + head mobilization) as bimanual laryngoscopy, as they are both activities that the laryngoscopist does with their right hand -- conceptually, that makes me think of both of those very helpful maneuvers together instead of as separate entities.

It's also a gentle reminder that to use 2 hands on the thyroid cartilage (and oftentimes large-headed patients might need an extra hand under the head as well!).

Euler Diagram (evidently slightly different than a Venn)

Update: Two slides from Rich Levitan's Grand Rounds:
cricoid pressure = bad

Update: Javier Benítez showed me this Levitan video on BL/ELM vs CP:

March 13, 2012

SinaiEM Lectures

there are over 50 past grand rounds hosted on sinaiem.org (http://www.sinaiem.org/academics/lectures/) and a few more on the way

please let me know if any links are broken!

unfortunately some of the audio/video quality is poor

here are the best-of-the-best, in order that they're on the page:
makes you wonder why you thought this was so hard
Dr. PE talks about the problems with our philosophy of diagnosis
emcrit vs smartem: how to diagnose a pe
from the first All-NYC EM Conference 2011 (8/31/11): The Ultimate Diagnostician (30 minutes or less)
aortic dissection diagnosis made simple
brief overview of how everything we do in ACLS is useless
great little summary
see also: 3 videos of sock puppets featuring reuben strayertestingdiagnosis, and screening
Joe Lex talks medical errata
best overview of the why it's so loud in the ED
great overview on out-of-hospital arrest, leads into well into chest-compression-only...
succint argument on chest-compression-only CPR. i'm convinced.
the master of low risk chest pain on why i'm not smart enough to rule out MI without testing
everything you need to know to master alcohol withdrawal
more than you ever thought you'd need on strangulation, and some great points on contrast
these are talks i haven't listened to, or i was at the talk 3 years ago and just don't remember it, but look promising. in my queue, and i'll update this as i listen to them.
from Information Systems & Social Media: 2011 Mount Sinai Emergency Medicine Affiliates Meeting (3/30/11)
grand rounds: