Video learning in emergency medicine

"He who opens a school door, closes a prison"
(Victor Hugo (1802-1885) French poet, dramatist and novelist)

Education is everything. It is the sole reason I have started this blog. IT is making education reachable to everywhere and everyone. Physicians already have access to the worlds best medical libraries through excellent textbooks and hospital libraries but they are slow to browse and search and limited to physical locations or availability. The IT revolution is made of many small revolutions. With the advent of sites such as Youtube and TED talks, multimedia education is one of these we are facing right now.

Emergency medicine has a lot of great multimedia sites today. It all started with the podcast revolution but we are seeing more of lectures coming online in the form of videos. If a picture says 1000 words you can imagine how many words a video tells. I would like to tell you about some of my recent discoveries as I believe these will significantly change the way we will learn emergency medicine in the future.


It all started with my Google-ing of common topics like anticholinergic intoxicity, hyperkalemia and general ED scenarios. Some sites came up again and again and, ending up in my bookmark collection and I remember Free emergency talks being one of the first ones. I started really liking some lecturers - names at that time completely unknown to me (except for Billy Mallone who has visited my ED in Reykjavik/Iceland on a several occasions). Amal Mattu, Joe Lex, Stuart Swadron... Actually listening to Amal Mattu's cardiology updates was a life changing experience for me, emergency medicine-wise at least! Never before had I realized the importance of learning from the viewpoint of emergency medicine. After all it is we emergency physicians who are the filters of the hospital, the gatekeepers, the ones who decide if patients go in, out or somewhere between. Why should we bother ourselves about the abyss of chronic a-fib treatment options when our role is to stabilize and admit the a-fib patient who comes in hypotensive and tachycardic! Surely we don't care about the 100+ differential diagnosis of hyponatremia when the most important issues for us is how to manage those who have seizured and have a suspected central pontine myelinolysis?! Well for me as an emergency physician in Scandinavia where EM is a young specialty, this truly was an eye opener. EPs in USA, Canada, Australia and UK have been there already but maybe your seniors will remember those days when your specialty was young.

So I started browsing the Internet to find the sources of all these excellent lecture givers. For weeks I stumbled upon new sites and I came to realize there was a whole lot of things going on digitally in the emergency medicine Web 2.0 community. I found great blogs, podcast sites, EM:Rap... check my list of primary emergency medicine resources (the most popular post yet according to the statistics of my blog) for the review of these. My style of learning emergency medicine was changed forever! This post is focusing on video learning so I will not write more about my "weeks of wow!" but to make a long story short, there were video containing websites I repeatedly got back to. This turns the scope to a college who has changed our way of learning emergency medicine.
It turns out most (almost all!) of them are the product of a genius, an emergency physician the medical society will someday make a statue of (or at least a special hat!). Let me introduce Mel Herbert (click link for a short video about his work), the Australian emergency physsie (I guess they say it like that down there) now practicing in USC, San Francisco. Although he is involved in some of the lectures himself, his contribution most importantly is that of making the lectures digital and putting them online in an easily accessible format. As an all-digitalized physician my self I know the huge amount of work he must have put into this. In addition to all this he also manages to give birth to a monthly EM:Rap session - yet one of his amazing creations. So let me introduce to you Mel's offsprings and what they will do for you!

USC Essentials

$450/year, $98/year for residents.
I guess most of US emergency physicians have heard about this great conference which runs annually (since 2001?) on the West coast with lecturers and attending guests coming from all around the US. Their lectures are straight-to-point, appropriately short and very practical. One session at the USC Essentials and you are as much up-to-date as you possible can be, perhaps only second to ACEPs annual scientific assembly. There is the USC essentials main course but they have spiced the conference with subdomains such as ECG reading (Amal Mattu onboard!), trauma, ultrasound and orthopedics to mention a few. Check out the menu on their website and you'll get a grasp of the content, there are even a few free lectures online for you to peek in your nose and sniff a few molecules of the Essentials atmosphere.
This was the first site I stumbled upon and I am still browsing trough their archives and my jaw is simply stuck on the floor. Corey Slovis' short and tactile approach to hyper- and hypokalemia, Tom Mailhot's two minute ultrasound examination of the patient in PEA (shock), Amal Mattu's cardiology updates and the legendary Greg Henry (former ACEP president) on medical malpractice... this is heaven for emergency physicians!

Emergency medicine Core content

$299/year, various discounts for residents/students.
At USC they have a weekly residency conference where residents, attendings and even consultants give lectures on common ED topics. As expected their approach is a little different to the more "sexy" USC Essentials - they cover more of the basics, all the differentials (even the rare ones), background physiology etc. Also, Core content has something USC Essentials hasn't - audience discussions and dialogs from which I have learned invaluable pearls of wisdom. Especially as they have excellent physicians such as Billy Malone and Stuart Swadron unwinding wisdom from their years of ED experience, like mature and aged volcanoes spewing hot and molten lava high up in the air!

All LA

Free!
The little brother to EM Core Content, these are from the Los Angeles EM resident conferences. The lectures are of no less quality but they are not as many. Just as Core content hey cover very interesting (and practical) topics such as valvular emergencies, trauma and pediatric emergencies - specially I like the panel discussions such as this one where their faculty discusses ACS therapy, PE diagnosis & PERC rule, beta-blockers in ACS and much more. Occasionally they have guest appearances from USC so for free you can view some of their great lecture givers such as Stuart Swadron and the USC chief residents whose lectures I have watched with admiration on the Core Content site.
If you want to try out using video lectures for free, this is a highly recommended site to try out.

EM:Rap TV

Free!
Yet another Mel product, this is a bit like EM:Rap but in video format. Short, concise videos from all corners of emergency medicine;  Mel reviewing the literature, guest appearances teaching common ED procedures, IT news... I see it as an entertaining TV station for emergency physicians, with bits of valuable educative pearls popped in every now and then.
So that's what I have found from Mel B's chocolate factory but there are other sites out there which I have to mention too.

CME download

One time $350 subscription.
Backed by The Center for Medical Education which is a 30+ years old foundation, this is no small project. It has a collection of 2.000+ video lectures from some 30+ different conferences, many of which I have never heard of and others which sound really exciting (like "Virtual procedures", "Airway and sedation" and "Expedition & Wilderness Medicine Conference"). There are some big ones there like the National Emergency Medicine Board Review which I would really love to delve into some day as it's educational value must be humongous. You can see a list of their courses right here.
Unfortunately I haven't had the time to review this one either but only from seeing the frontpage of their website, this must be an excellent library of educational videos. Considering the one-time price of $300 it certainly is a bargain too. Hopefully someday I will be back with a post about CME Download.

Others

• EMedHome is worth mentioning since they have high quality emergency physicians on board such as Amal Mattu. They have a few videos on board but those are not whole length lectures as those above and limited to special clinical findings such as an ultrasound diagnosis or examination of an Achilles tendon rupture. They seem to have started with online lectures but I can only find three of these so I assume they decided to focus on their database of excellent articles and podcasts which I hope to review some time in the future.
• Besides this, there are the usual videos at Youtube but they differ enormously in quality as there are thousands of medical videos there. My approach has been to create an account and playlists where I save those videos I want to keep, mainly ED procedures as viewing the video is so more effective than reading the textbooks. There are also some nice channels (kind of playlists other users have done) you can subscribe to. This is material for a later post.
• BMJs educational videos are an honorable mention and need no introduction since they have been around for years (some of them are available on Youtube). Then there are many many ultrasound websites out there. For all those smaller video resources (and actually video webs in general) I'd like to point out an excellent article the Life in the fast lane dudes have published.

That was all folks, the top video sites for emergency physicians in autumn 2010. I hope you have got at least a minuscule of the excitement I have for this revolutionary education form we are witnessing right in our back-yard. Obviously there are great varieties of the video format and how they are presented on websites but when it comes down to it all, it is the lecture and the lecturer who are the most important. I remember the names of the great lecturers more than the websites I saw them on as well as the content of their lectures. Therefore I am really excited to know if ACEP's scientific assembly lectures will ever come online, that would be *the* ultimate thing. I have made several Google attempts to find out if these exist but without success, yet.

Streaming video technology is just a platform for bringing that good and old style of teaching to our computer. The technology breakthrough is that you don't have to be away from your family for days or pay lots of dollars for attending the conferences but instead have it in your laptop at the comfort of your sofa, in your mobile phone while commuting or in the gym or just on your desktop PC at work. You can view it whenever you like, making use of the various "dead time gaps" found in your daily life. You can pause the video if you are suddenly interrupted to continue later and you can even adjust the playback speed at your needs to maximize the use of your time. This is simply THE most amazing way of e-learning.

To finish this off I would to point to a wonderful TEDs talk about the impact of video education.

Crocodoc- for your PDF collection

An electronic (paperless) office is key to success in a world overloaded with information. Using the data cloud you can have it accessible at all times and everywhere - at home, at work and even from your smartphone while commuting. For a doctor who is keen to constantly learn more and stay up-to-date, a mobile office is it. Actually a mobile office is much more than putting away the papers, it's also the concept of having your office tools at hand, everywhere and anytime. Contacts, calendar, email, chat... the list goes on. I will soon bring you a big and juicy post about my personal configuration which I have developed for years. For now I will tell you about one particular part of my e-office, how I manage my PDF documents.

For most documents (images, text files, notes...) I use Google docs and actually Google apps is the base for my e-office. Although Google docs can store PDF files and has a very nice online viewer there is a crucial tool missing, the ability to highlight text and write notes.

Every doctor has a collection of memorable journal articles which they have read thoroughly and want to keep for future reference. If you are as me you strive to have all reference books in electronic format. Some will be accessible online (Rosens Emergency Medicine is available online at MdConsult for example) only but others downloadable as PDF files. Just as you've dried a few kilos of marker pens while doing your stud med years you will want to highlight your PDF collection as well. There are nice applications for this, my favorite one being the free and excellent Foxit pdf reader. But it's not an online web-application (actually, it is a "desktop application") and so doesn't fit into my mobile/online office configuration. I don't want to install it on the 10-15 different computers I have access to at work and then move the PDF files between work/home/wherever-I-am... you must see it will end with a disaster.

Earlier this summer an amazing web application appeared on my radar for which I have fallen in love with. The name is Crocodoc. With a (free) login you can upload your PDF file and store it on their server for later access. It can even take an address of a web page and convert it to PDF. Once you got it there it will open up in a special viewer where you have all the highlighting and commenting tools you ever need. Now you will start to understand why I'd love to have Tintinallis Emergency medicine in a PDF file!

And so, my real physical office is completely free of papers and I can access my PDF collection from anywhere, with my highlights and comments just as I had wished for. An amazing tool!

While we are at it there is another online web-application I'd like to mention which works with PDF files. PDF escape is the only online PDF app I am aware of that allows you to upload a PDF file and then edit it's text content and fill in forms. I have used it a lot to erase patient IDs from ECGs I want to keep. It's free and let's hope it stays free.

I would be surprised if Google doesn't advance it's PDF features in the very future, making Google Docs the ultimate office tool. Actually I really hope so since I want to have as much as possible in one place.

Discussion forum for emergency physicians - hot or not?

I guess most of you have participated in some kind of discussion forum as there are thousands of them out there. They are a convenient form of communicating with other internet travellers. The discussions are archived so that you can browse or search through earlier topics and usually you can see more information about the other users on the forum. This is to compare with an early invention of the Internet - the good and old (email) postlists which are still pretty common today. I still remember a trauma postlist I was a member of. It had very interesting discussions, for example the classical one about whether or not to insert a needle into the 2nd intraclavicular space in traumatic cardiac arrest. Having the  most eager trauma specialists of the world on board meant it was a heated but professional discussion. This level of activity has never been reached in a good emergency medicine forum.

Well forums in general maybe don't have a good reputation as well intended and professional arguments tend to be killed in the end by emotional havoc, leaving the forum participants angry and irrational (since we are talking arguments, there is one that is so funny it will unwind your intestines... Monty Pythons argument clinic!). Then there are those that only want to stir up emotions, the net trolls. Still there are quality forums out there and it seems that the longer they have lived the better they get, probably as the members get to know each other better.

So I have often wondered why on earth we emergency physicians have not got a decent forum for our community? Almost every day I have a question of some kind and am burning to have it answered; a ECG riddle, clinical decision point or whatever. Every now and then I wonder "how do they do this in other countries" as comparing treatments between continents often has it's interesting pearls of wisdom. In my emergency department in Lund (Sweden) we are a very young specialty and we are very commonly hitting the walls of other specialties. So often I would like to learn from the experience of my colleges abroad who have been there and know how particular obstacles were solved. A common discussion forum is a perfect place for this.

I have to mention BMJs very interesting experiment, they have a recently launched sub-site called Doc2Doc which has the goal of "connecting doctors worldwide". It is the best try I have seen yet and they seem to be aware of the net troll problem as only doctors can register and each and every registration is processed manually. Which means they actually check if you are a legitimate doctor in your country. Impressive! There are lots of features within Doc2Doc such as the ability to start your own blog in there - all in all it is a light weight social networking site like for example Facebook - but for doctors only. I did try this out and must say I am impressed but I have not touched it for a while now as I was overloaded by information that I did not need. I am only interested in emergency medicine, the best training centers for GPs in UK or treating acromegaly surgically or medically does not touch me at all. And so I put it on ice but I will be keeping my eye on this interesting experiment.

Besides that, there are several websites having the same idea and I will not delve into them here since I have not found any with an active EM group. It all comes down to one point - we want it simple and familiar. We don't have the time or energy to try out yet another website which may or may not be worth our time. Doctors are really lazy and impatient when it comes to getting to know new websites. Then there are already thousands of passwords and web addresses we have to remember at work and every new login to remember has to be for a very good reason.

So what about the social networking sites we already know, have a login with and are familiar with? Facebook, Google groups and LinkedIn are the ones everyone knows and all of them have tools for easily creating a discussion group. Most of us already have a login at some of these sites and starting a forum for emergency physicians is really easy to do. I did a quick search of "emergency medicine" in all of these sites and well there were a few hits but none of them very active or rich of members.

I must say, I really don't understand why someone in our tech-savvy EM group hasn't been there and done this. Now that the technology is there, easier then ever before and completely free - it makes me wonder if there is some other hindrance? Could it be that physicians are shy to share their thoughts in front of colleges? Or afraid of revealing some gap in their medical knowledge? Or just find new technologies scary? I really don't know! What do you think?

Video-learn 20-50% faster!

I just love sucking in every new gadget, website or tip that allows me to learn emergency medicine faster than ever before. I believe e-learning is the field where we have gained the most from information technology and as such I believe that in year 2010 we are much better (informed) doctors than only 10 years ago.

I have recently discovered the wonderful world of video lectures in emergency medicine and it turns out there is amazing quality stuff out there which I plan to summarize very soon in a special blog post. It is just amazing to be able to sit in my living room or other convenient places and watch lectures about aorta dissection, ECG in pulmonary embolism etc. - just as if I was there. Never before have I wished as much to have consiptation - an excuse to sit in the WC with my Android all day long! As said, I will be back with those video sites but first this one small tip which will speed up your video watching by 20-50%.

VLC player is an amazing (free) software which has the goal of "playing everything you hit it with". It is not the prettiest but it a Swiss army knife of video players. I recently discovered a "play speed" feature which to my amazement worked just perfect since usually the audio will be too distorted to enjoy. This very probably can be done on other video players as well but I like VLC's way of allowing you to fine tune the playback speed, it's not only in steps of 50%, 150%, 200% etc but everything there between.
Then you can even jump back and forth through the video with keyboard shortcuts, making jumps in steps of a second, 3 secs, 10 sec or whatever you like. With this level of controls at your fingertips it is easy to step back when you feel you missed out some important part of the lecture. Also a great tool when you want to re-watch some lecture you have seen before for the sake of understanding it better.


This little tip has made it much easier for me to browse through my collection of 2-300 of amazing emergency medicine lectures I want to digest in the winter months (totalling to about 150 hours of video!).

Using the RSS power of Blogger (Blogspot)

RSS is THE technology to stay up to date in the blogsphere. Here is a quick tip for you bloggers out there who want to use RSS to the extreme.
Everyone knows that all new posts can be subscribed to by the general RSS feed. The path to this feed is easy to find from the "subscribe to posts" link which for my blog is:
 http://pricelesselectricalactivity.blogspot.com/feeds/posts/default

In Blogger settings you can prefer to have an email sent whenever a new comment is written. You might want to have it in your RSS reader instead - or even create a gadget to stream it in some custom way, the possibilities are endless. The path to the RSS comments feed is:
 http://pricelesselectricalactivity.blogspot.com/feeds/comments/default

or if you want to watch comments for a specific post:
http://pricelesselectricalactivity.blogspot.com/feeds/6234880912964361746/comments/default
Those numbers there are the postID, which is a unique identification number for each individual post and is found in the address bar when you edit the post (actually you can also find your blog ID in the very same address).

Blogger and Blogspot are to the user the same though under the hood, Blogger is a free publishing platform, while Blogspot is a free domain service provider. If you are craving for the details you can read more about it here.

In some blogs you may get overloaded with posts that you do not care about at all and you just want to read about a particular subject. Say, for example, that you only want to subscribe to my IT-tips which I tag specifically. Well it turns out that Blogger can actually give you feeds by tags, you only need to dig up the URL which is well hidden under the turf. The URL then is:
 http://www.blogger.com/feeds/[yourblogID]/posts/[feedType]/-/[labelName]

Hmm that wasn't as easy! Well you know already how to find the [yourblogID] from the adress bar and to make it simple we use "summary" for [feedType].  So a RSS feed for my IT-tips would be:
  http://www.blogger.com/feeds/2248583521093048479/posts/summary/-/it-tips



OK that's all. There are many more options for your RSS feeds such as how much text they should include, how many items etc. and if you want to dwell into this there is more to read right here:
http://www.bloggerbuster.com/2007/09/all-about-blog-feeds-part-1.html

Non-surgical causes of abdominal pain

I have come to the conclusion that emergency medicine surely must be one of the most difficult specialties in medicine. We are the the only gate-keepers to the hospital and it is our decision if the person walking in to the ER is sick or not and then if there actually is anything with that symptom that needs follow-up. Amal Mattu in his excellent ECG course has often pointed this out with regards to ECG interpretation - it is the emergency physician, not the cardiologist, who will pick up the pathologic pattern before disaster happens. Take Brugada and Wellens as an example. Treating the patient is not the difficult part, ruling in and ruling out is.

So every now and then I like to read about the not-so-common diseases which just might pass through my ER and I am responsible for reacting on. Abdominal pain is one of those traps where delay in diagnosis can cause misery to the patient. If it isn't appendicitis, cholecystitis or diverticulitis I try to strain my brain cells and think twice before deciding what to do with the patient. Often it's just back to basics and so it was a joy to stumble upon this great article from BMJs medical student journal:

Non-surgical causes of abdominal pain
It will help you think broader next time you have that abdominalia that simply doesn't fit into the common disease patterns. Tabes dorsalis, lead toxicity, porphyria... oh common don't tell me you already had these on your ddx list!

What's the date?

Commonly I look over the shoulders of my colleges and see them taking unnecessarily many steps to do simple things. One such is the task of finding out what date it is.
Everyone knows how to find the clock, it's located in either bottom or top right corner on most modern computers. Well what you maybe didn't know is that if you take your mouse pointer and move it over that clock, the date will pop up instantly (don't click the mouse, just move it there).

That's all folks!