The best podcasts I enjoyed in 2011

Now that Christmas lights are finally brightening the dim afternoons of Scandinavia my mind is drifting and looking back to review 2011's top events. A five hour trip by car from Stockholm to Lund in July comes to my mind where I listened to some great emergency medicine podcasts, making my fingers tickle with excitement to get back to work after a well earned summer vacation. My kids so quiet in the backseat and my wife reading Game of thrones besides me, this trip was a e-learning blizz. Now that I look back I see that thanks to newly discovered e-learning resources, I have never before learned as much in a year as before. I consider my self a much better doctor, thanks to great colleges out there sharing their learning experiences and discoveries.

And now I would give back and share with you those podcasts I enjoyed the most this year, hopefully inspiring you to try out the 'road lesser travelled' and waking up to the fantastic world of e-learning. Here they are, in no particular order:

1. Having just had a tough case of bleeding aorta aneurysm with atrial fibrillation, Scott Weingart's rant about the crashing atrial fibrillation patient helped me understand better how to approach this 'shit has just hit the fan' scenario. This was how I discovered Weingart's amazing, almost aesthetic, collection of podcasts, bringing me EM wisdom in an unprecedented way.
2. Scott's "Sympathetic Crashing Acute Pulmonary Edema" rant is also a ten bagger, I will never again be afraid of the dyspnoeic patient having razzles up to neck level.
3. I have yet to dig through EM:Rap's wonderful collection of excellent EM lectures from all around the world but of those I've heard have already become all-time favorites. Especially I remember Michael Chansky's Diabetic emergencies as a total wow moment, the talk was so rich of valuable pearls I actually listened to it three times!*
4. Stuart Swadron is one of my favorite EM ranters as the clinical pearls coming from his mouth are non-stop. Mel Herbert actually calls him "captain cortex" as he remembers the most petit symptoms and conditions. Earlier this year I listened to his discussion with Dr. Lopresti (who's seen more myxoedematous comas than any other physician!) about severe hypothyroidism in the EM; the ominous yet subtle presentations that you could easily miss in your ED. If you haven't already that is... In an hour's listening I learned more than my 3 month rotation to the endocrine clinic. In EM:Rap's june 2010 episode the same party discussed hyperthyroidism.*
5. At Kos 2011, I had the fortune to enjoy Joe Lex's stunning talk about the assassinations of the american presidents, from the medical perspective. A lesser known fact to the world is that some of the deaths may actually have been early recordings of a medical malpractice as the patients (the presidents) were treated with utterly unsterile techniques. As Guiteau said himself in court: "The doctors killed Garfield, I just shot him". Even more stunning though is that these talks are free to listen to from freeemergencytalks.
6. Definitely not the most educating EM podcast but absolutely the most entertaining one, what else would you expect from Mel Herbert? "Famous Deaths!" from Doctor's Unplugged and make sure you have plenty of floor space to ROFL!
7. You know Rosen's textbook of Emergency medicine... well can you imagine this respected author and honored emergency physician telling you about the first years of emergency medicine, back in USA in the 1950s? Be prepared to hear one of the most interesting and even shocking EM talks you'll ever hear; Peter Rosen: Beginnings of Emergency Medicine. BTW Rosen's talk can also be viewed on All LA as a video-talk.
8. ICU Rounds is a non-EM podcast site but hellya the overlapping of these fields is so extensive anyways, it's just like two sides of a slice of bread... (I already hear the footsteps of ICU trolls coming to my blog). A podcast about acute kidney failure had all of my attention this year and has taught me wise things about a scenario which is otherwise so boring to read about that the textbooks are soaked of drool from snoozing.
9. Amal Mattu is an old favorite of mine and his talks were in 2010 my eye opener to the world of podcasts, as I discovered the freeemergencytalks collection. This year I listened to his great talk emergencies in the geriatric patient - a gentle reminder that the elderlies are not to be taken lightly in the ED.
10. Finally, something to remind you that the world of podcasts is just half the story - there are also lots of excellent 'videocasts' out there; talks from the big conferences, academic lectures, grand rounds etc. They might not be a thriller for you working in an academic ED where emergency medicine has been alive for 50+ years but for me where we're almost in the startholes, without senior specialists with experience dripping of their clothes, having a video lecture with occasional academic shouts from the audience in the background has changed everything... I've seen a lot of good ones in the year and I can't easily say one is better than the other but the USC case presentations, escorted by Captain Cortex amongst others have had a great impact for my learning curve. Try for instance this excellent presentation of two mystery cases - just sit back and enjoy!**

That will be all. If you're new to the fascinating world of blogs, podcasts and vodcasts I have a not too long yet detailed introductory post for you to prepare for your first e-date. By the way, I would really like to see your highligths too, please feel free to jot whatever sits at the top of your heads here below in the comments!


With that said I wish you all a happy Christmas and let's hope I manage before 2011 is over to finish my post about Linux - aren't you curious to know how that can have anything to do with emergency medicine!

* I decided to use this as a shout-out for Mel Herbert's excellent EM:Rap, if you haven't heard of it before then read my lips: you are missing one of the greatest educational sources for emergency physicians, ever! EM:Rap is not free but you will not regret a single cent of your purchase. To prove my case I have uploaded the above mentioned podcasts for you to try out (with Mel's permission).
** The same goes for EM Core Content, also a Mel Herbert production. As you might have noticed, Mel Herbert is a very productive physician indeed and I seriously suggest you read my post about his wonderworks! Please notice the video quality is consciously reduced as this is only a introductory video!

The Bristol Stool scale

Next time you want to gain some points when talking to the house surgeon you could report your patients' stool characteristics with the professional Bristol Stool scale... Expect at least 3-4 seconds of silence on the line!

Ask a friend - the universal EM questions experiment

My emergency program here in Lund (Sweden) is one of the first in Scandinavia and for that we are proud of. Our ED is a well functioning one with ambitious residents. There is no doubt we have had enormous help from modern IT and social media, especially since we are a totally on our own whereas the program is only 10 years old. I am not sure Joe Lex understands what an impact his Free emergency talks has had for our group, giving us opportunity to listen to the great talks from the big conferences - that was how it all started.

The problem is still that we haven't got so many to ask when our group is exhausted. But that doesn't silence the hunger for an answer, in the opposite the frustration just grows.

I am sure there are other colleges out there, in dark corners - having exactly the same problem. So I decided to start an experiment to see if we can relief the frustration with modern crowdsourcing. Therefor I have started a Google Docs document, open for everyone to edit, with a few questions from our group to kickstart this project. Michelle Lin (UCSF) has previously had experience with Google docs crowdsourcing and has a huge interest to in EM academics so I asked her to help me and she even has a question on the list, waiting for a clever EM physician to answer. Should this go well I am prepared to take it a step further and develop a better platform but currently I think Google Docs this is the easiest way to start. Remember if you have a Google account the document will reside as shared on your GD home page and be bolded everytime there is a new question/answer.

Alright, everything is set and we are ready to go. The magic link then is
https://docs.google.com/document/d/1oDFuaYJrOT5UJolsmgudVfdLSkeYvuTsMkmVpz7d9Ds/edit

ADDENDUM feb 2012

Judging by Blogger statistics this post has had very many readers so I assume the idea must be something my colleges are interested in. As I had suspected the text based format is not the best one if this is to roll on, for example there is no way to "upvote" a the best answers and just pushing answered questions further down is no good way of archiving old questions.
In the meantime I have discovered Quora which seems to fulfill all our needs of an easy, web-based Q & A tool for asking and answering EM questions by the community. Although not locked or restricted, it's tagging and grouping system would make it incredible easy to use for the EP community and being a modern social-web based tool (for example using Facebook login credentials) it has the potential to become the true tool I was looking for. The one thing we need is more EPs to sign up and start using it and as such I suggest you all go there and start following the Emergency medicine group.

IT for emergency physicians - the esoteric talk

In september 2011 I was at the 6th MEMC, an international emergency medicine conference held in the small greek island of Kos - the birthplace of Hippocrates. I was given the opportunity to talk about my IT experiences in my life as an physician.

The thought of a first first time talk on international ground was comfortably stressful until the day before when I decided a trip to an Irish karaoke-bar would stabilize my nerves. And it did but the irish bartender spotted my Acchiles' heel and managed to sneek more beer on my table than I had planned for, fiddling most of my cortical senses and spinal reflexes the day after.

There was a silent nervous breakdown going on and standing in front of tens of ED docs, masters of spotting obfuscate symptoms, it was a little hard to give "the perfect talk". A faux pas for martians even. Fortunately the content of my talk was of more interest than performance and it seemed the audience forgave me stuttering words with a mixture of esoteric swedish, icelandic, english-wannabe pronunciation. I even had a short-lived crowd gathering afterwards asking for my name tag and email which I like to think was a positive sign.


And now, I give to you a "home edited" version of the same talk, with the same esoteric pronunciation for you only to feel the atmosphere of the real talk...

Keep in mind I was limited to 20 minutes and to dissect a broad topic as IT in such a short time would be utterly impossible. Instead, I give you a few eye-openers and ideas for you to step onto the IT-wagon yourself and I welcome you to follow my blog for the details.

Please feel free to ask any questions you have in the comments and I will happily reply. If you find an urge to discuss with me karaoke as stress-relief therapy, you are welcome to contact me - you will find contact info in the introduction post.




IT for emergency physicians from David Thorisson on Vimeo.

8. Online security - preventing your digital catastrophe

I have just read an article about a womans' great misfortune where her Gmail account was not only hacked but all her online data erased. A chilling reminder of how vulnerable we are with our life stored in the cloud; years of correspondance, documents and personal photos. An event like this would leave me stunned for weeks as most if not everything I have created is now online. The article is a must read for everyone, it is not only a wake up call but  a lesson learned how to defend your self from modern crimes - being hacked online.

Being both paranoid and proactive I have never in my years of computing had an intrusion, neither at home or online. As IT engaged doctors, defending our online forte is on of our most important tasks. Unlike other physical things that we insure because they can be replaced, the day that you are hacked is the day you can loose it all. Thus I would like to share with you my experience and techniques.

Please remember to also read the article, they are 10 minutes well spent!

Protect your email address

A login is a combination of password and email. Thus keeping your primary email away from the Internet is a strong tactic of defense since the hacker has no way of cracking your password.

I have two Gmail addresses. The primary one I give out only to those I fully trust, thus mainly family and friends. I would even hesitate to give it out to people I am not sure about since if their email accounts are hacked, my address will most probably go to some hacker's database and thus online. The other email I use as my "shield" and I use it for registrations, postlists etc where anything can happen.
Then I use the primary Gmail account to import from the secondary one. Gmail's spam filter has then automatically removed 99% of suspicious emails and even though a few "genuine" emails get caught in the spam filter I don't care since they're not personal anyway.

In the end your email will eventually leak (in my case, my mother's email account got hacked, I never had spam emails until then) but this technique minimizes the visibility of your email. This is why I also use my secondary email for postlists or online orders, even though I trust the companies they just might get hacked one day and the hackers most surely will be looking for gmails to hack!

Secure your password

Hackers are not guessing your passwords today and trying a few entries until they give up. They have robots which make "brute-force" attacks on your accounts with thousands of words per second, combinations of words caught by spying your online social life (e.g. birthdays and children's names) and a pool of "most common passwords". Not only do you have to choose your password carefully but you should renew if at least every 6 months. The IT friendly site Makeuseof has a nice article on creating a password a little harder to break, if you really want to dwell (highly recommended!) into this subject I can also recommend Lifehacker's articles.

A very common mistake is that of reusing passwords. You might for example have the same password on your Gmail account as on some general news-site, say your subscription to Wall Street Journal. Hackers know this and therefor put efforts into breaking into the databases of these seemingly non-important sites to catch logins. Someone breaking into my WSJ account is utterly unimportant to me - at most the hacker will be able to read some locked WSJ articles but they will not be threatening my online world in any way. My online bank login on the other hand is a very vulnerable one obviously. With so many online logins to hold account on you need to define which ones are truly vulnerable and take special care of these. For the rest, you can ease your paranoia and reuse your password. This will also make it much easier to hold account of tens of logins as modern IT life requires us to do.

With special care I mean choosing your password wisely, renewing it on regular basis and storing it carefully. There are many nice  software solutions for this, I prefer phone based ones since I have my phone always with me and thus easily used for looking up not only web-site passwords but PIN- and door codes. For this I use the highly recommended Android  app Pocket - there are iPhone apps for this too.

Beware unsecure wireless networks

Modern hackers will not only try to pick lock your passwords - another less known method is that of sniffing network traffic to eventually find your password amongst millions of data packets. It may sound difficult but this can be done in just seconds with software easily found on the Internet. Free networks ("hotspots") are available all over, especially in caféterias where you are welcomed to sit down with a nice Cappuccino to browse the Internet and do your work. To save you from the hassle of logins the hotspots commonly offer open WiFis meaning that every single data packet coming to or from your computer is open to the public. If you are like me you most probably have accessed these WiFis with your smartphone, I have to admit I hadn't realised the danger of this until I read the article above.

Your only protection is to be truly paranoid and avoid unsecure WiFis. If you insist, minimise access to your personal sites requiring login.

This is impossible, I know. Fortunately there are less dramatic alternatives - securing browser traffic with https for example (see below) and using VPN (virtual private networks). Until you feel totally sure about your hotspot vulnerabilities I recommend you to use your laptop lightly unless you have access to a secured WiFi, some cafeterias actually do provide their customers with a password for this purpose.

And remember to check your WiFi setup at home - the once trusted WPA protocol is now easily hacked and you should only be using WPA2.

Now this is not something for the average computer user to understand from just one blogpost. Because how truly important this is I highly recommend that you give yourself some time and read more about WiFi security, here is a great website which will cover the basics in an easily read text:
 http://www.nowiressecurity.com/about_wi-fi_security.htm

Be very afraid of malware

In the early days of PCs you were required physical actions to install software such as inserting a CD. Today the mere click of a link is enough to wreak havoc, unless your computer is well protected (Windows is especially vulnerable). Malware is tiny piece of malicious software - computer virus is one kind of these - built with the purpose of taking over your computer or parts of it for various purposes. The least scary ones just want to use some of your CPU power for a bigger project while the true beasts will record every single keyboard stroke, waiting to catch your passwords or credit card numbers. What is most frightening with malware is that they will commonly install themselves without you noticing anything, sitting in the background waiting for you to fall to it's mischiefs, like a spider in it's net.

Unfortunately there is no one solution to fight off malware but having a decent anti-virus software will do it for most of these - at the same time clogging your computers' resources (some will take up to 20% of your CPU). This is one of the reasons I am totally converted to Linux - something I will be blogging about in just a few days.

Pick your browser

Internet Explorer used to dominate the world of browsing thus becoming a popular target for hackers. A depressive fact considering so much of your work goes through this wonderful technology. But then, IE simply is awful when it comes to security and has caused many days of embarrassment at the offices of Microsoft. Yet another reason to switch to other browsers not only more secure but in every aspect better than IE.
You might have noticed from previous posts my love for Chrome, the fact that Google has offered $20.000 to anyone who claims it can be hacked says all that needs to be said.

Special tips for your Google cloud data

The article told about an unfortunate Gmail user and being a very active G user my self I want to emphasize a few points which will dramatically reduce the risk of you being hacked, in addition to those above.

• Set Gmail to use https, secure connection. This is your last forte e if you insist on using unsafe hotspots (see above).
• Activate Gmail's 2-step verification; this will disarm anyone who is even making an attempt to hack your account with the little cost of occasional verification codes.
• Activate the recovery options in case you loose your password, it will give you more confidence while picking a truly uncrackable password.
• Beware suspicious links in emails! Although Gmail's spam filter is doing a hell of a good job, an occasional email will slip through and commonly they seduce you to click a link. Which could be the beginning of your worst day of life. Be informed and you won't run into this trap.
• The spam filter works so well because it's crowdsourced - Gmail users report fraud email and the servers will automatically act when a particular email is being repeatedly reported. So it is important that you as well flag mail that you consider fraud, this is easily done with the "report spam" button.
• A backup of your cloud data on Google's servers will give you the ultimate feeling of comfort and good nights' sleep. Here is a great article on this subject and fyi there are rumours about a Google "Gdrive" coming with function simliar to Dropbox. Which would mean automatic backup of everything in Google docs - and maybe more.

See also

• Kill the Password: Why a String of Characters Can’t Protect Us Anymore
  "This summer, hackers destroyed my entire digital life in the span of an hour"

Cardiology updates 2011 is out!

The world of podcasts is a truly inspiring one, especially in emergency medicine where it seems there is more ambition and spirit of 'sharing knowledge with the rest of the world' than in any other field I know. Although I regularly encounter great lectures this way I decided my blog is not the right place to shout these aloud.

I will make an occasional exception and this time it's Amal Mattu's "cardiology updates 2011", an annual podcast where he reviews the most important literature of the year. It was through these exactly that I caught the podcast train a few years ago and so I see a very good reason to let you know that the 2011 lecture is out.

Put everything else aside, this is the best thing that could happen to you this week. Thanks Amal Mattu and Joe Lex for putting this online. This kind of knowledge truly does lead to better patient care!

http://freeemergencytalks.net/?p=6241

Your calcluator always at hand

I've previously talked ranted about Google's web-browser Chrome and why you should master it to increase your productivity. Now here is a short tip I just picked up which will certainly save you time and mouse clicks while calculating your antibiotic dosing or critical care vital signs...

Google search is so much more than just a brainless search motor, it has built in special functions providing for semantic search (in short, semantic in this aspect means more meaningful) results, just try for example looking up your flight number, "weather xxx" for an inine weather forecast, "define:xxx" for a quick explanation of a word and it's synonyms... you get the catch. There's also a calculator so that you can throw any numeric equation at it you wish to have crunched.

The real magic lies in Chrome's address bar, as I've previously mentioned it has some amazing features making it much more than just a browser. This is what I'm talking about:

Thanks Guidingtech for teaching me this trix (well worth reading too, you can never know too much about your browser, the heart and lungs of your computer)!

Learned on the pedatric rotation

These are some of my learning points on my short pediatric rotation:

• A children's doctor is a pediatrician not a pedestrian!
• WBCs will rarely go higher than 20k for a pure stress reaction
• Children have a much more exaggerated glucose response to stress, isolated hyperglycemia does not routinely require follow up
• A tip for making an infant pee for urinary sample: put something cold on their stomach. Often it will be enough to just remove the diaper, the fresh air will do it!
• Do not forget the rarely seen but important to know ddxs to strep A tonsillitis;
• Vincent's angina: is a very aggressive necrotizing infection of the periodontal/gingival tissues commonly caused by Fusobacterium nucleatum or Treponema vincentii to name a few
• Lemierre's syndrome: primary tonsillitis with severe sepsis following by thrombosis of vena jugularis. Most commonly caused by Fusobacterium necrophorum.
• Ethmoiditis is an infection I had never heard of before but one of those that the pediatrician should have in his/her ddx list because of possible complications. I had subfebrile little girl with recurrent left orbital headache with discrete, hard-to-describe orbital soft-tissue oedema which we sent to the ENT for evaluation for E. This is the layman description: "Infection of the ethmoid sinus results in swelling of its mucous membrane, causing increased mucous production and nose block. Sometimes the ethmoidal infection can spread to the contents of eyeball and form pus collection. This condition is called orbital subperiosteal abscess."
• A patient who has GIT symptoms secondary to erythromycin should try lesser but more frequent dosage e.g. x4 instead of the common x2 or x3
• Betapred's (bethamethason) time of onset is 1-2 hours, peaks at 4h and duration of about 48 hours. Betapred can induce diabetes if used chronically but as usually the biggest worry is delayed growth.
• A pneumococcal vaccine does not neccesitate change of antibiotics even if suspected infection with these (e.g. otitis), it will only take the tip of the infective burden but not prevent infections.
• Capillary refill time seems to be a little overvalued for assessing circulation
  http://resusme.em.extrememember.com/?p=5167
• Never ever exclude streptococcal pharynigitis/tonsillitis in the febrile child with normally looking throat on examination - you will one day have a positive Streptest even though you were certain there was no focus there!
• Even the pediatricians are not really sure where to draw a line between bronchiolotis and bronchitis
• Vasovagal syncope in a teenage girl is almost invariably because of stress!
• SIDS statistics have changed a lot in twenty years and mostly thanks to academic research. The incidence is down from about 2-300 cases/year here in Sweden to 20-30, an incredible achievement where a single preventive measure (have infants sleep on back) is the single biggest factor.

The most important lesson learned though was the value of hearing a simple "I don't know" when asking senior colleges, an answer I fully respect and honor when appropriate. There is nothing more frustrating than hearing a long talk about everything but the original question and then finding out you are even more confused then when you asked the question. I will also this my self from now on!

Acute care testing

With so many new websites appearing every week I find that the 'word by mouth' - personal reference from those you know - is the only way to "stumble upon" new webs today. Here is one gem I'd like to share with you.

So often I have had test results showing what I didn't want to see; a high lactate in a perfectly well patient who wants to go back home or normal troponin in someone who screams acute coronary syndrome already by seeing him from the door. With so much traffic in the ED there is never time to pause and check the literature and if you call the lab they will only answer technical issues concerning their machines. They never see the patients and thus don't make clinical judgments, only bla bla their reference guides.

So what if there was a website where healthcare professionals and lab managers jointly push forward literature and opinions based on these, for you, the target-user specifically? This is what Acute care testing has to offer.

You can browse their collection of great articles on topics such as when d-lactate becomes significant (do you know even if your blood gas machine actually measures it?), clinical aspects of pleural fluid pH or an excellent article "Lactate and lactic acidosis" which actually was the one that led me to this fantastic site because it is happening all the time in the ED. This was exactly what I was looking for:
"In vitro glycolysis and therefore lactate production continues after sampling so that lactate concentration increases by 30 % in just 30 minutes if kept at room temperature"


So for lab analysis and thoughts, this is da shit!


---
ps it's impossible to talk lab results without mentioning Life in the Fast Lanes's excellent "Medical investigations" page, everything you need for quickly evaluating your abnormal lab tests on the ward!

Where has Google body browser gone?

A little shocking news has arrived from the Google complex about the future of an all-time favorite, the Google body browser. Now that many physicians have just discovered this amazing application it is frustrating to find out that this project is being discontinued. Or is it really?

UPDATE jan 2012:

All is good and well, Body browser is back online but now as "Zygote body"!
http://googlesystem.blogspot.com/2012/01/google-body-browser-is-now-zygote-body.html

It seems by digging into this news that it isn't at all, rather it is part of Google's decision to stop the Google Labs project and move on all projects within to a finite application but in the hands of other developers. Which should mean that projects that have been in a standstill for years are now pushed to faster development, a win-win situation for everyone.

The same goes for Body browser which will now go to a private company, Zygote media group, which has promised to offer it for free in the future. Their connection to GBB is their ownership of the underlying 3d body model. The viewer itself will also be taken over by the open source community.

Reading all this I've also learned about another similiar 3d project, the BioDigital Human. It seems theirs is even more advanced, for example allowing real-time dissection for. Competition is always good for end users and so with news seemingly sad news we actually should cheer out loud.

E-learning in emergency medicine

I had the fortune to be a medical student in the early beginnings of the Internet. These were the days when we sat in the library and were amazed that a message could be sent to the next table computer, making a window pop up on the screen just like that. In these days the specialists of the hospital were godlike idols, nobody would doubt their words or rival their knowledge in any way. Knowledge originating from hugging the textbooks, reading the journals and seeing patients and. After many many years of seeing one, doing one and teaching one they were walking libraries of not only facts but experience.

The basic ways of learning and gaining experience haven’t changed at all with the coming of the Internet but what has changed is that the cases, books, facts and learning points are now accessible everywhere and anytime. That is - ;if we know how to find them. The new method is called "e-learning" and here below are my tips for e-learning emergency medicine. Your medical students know these methods and that's why they are outsmarting you on your patient-rond. If you miss the e-train, you will also be outsourced by your medical students!

Google groups

As one of Scandinavia’s first emergency medicine programs we’ve had our ups and downs while trying to earn respect in the hospital. With strenuous working hours, corridor chat is essentially none and so we had no opportunity to discuss interesting cases or matters related to work. Google groups relieved this isolation. They key to it’s success was that it required no new logins or websites - a process bound to kill every kind of innovation involving busy doctors. Google groups uses the current email addresses to send out discussions but in the background also stores them in a closed, online archive which can be browsed and even searched afterwards. This way we share our important learning points; ECGs, blood gases etc. and in only one year our way of educating ourselves has reached a new level. Speaking of, there is actually an ongoing experiment to make an international Google groups list of emergency physicians, check out the link if you are interested.

Postlists

Although I prefer RSS to email based postlists, there is an exception because their quality is exceptional. University of Maryland has a list where you will get one email per day with invaluable clinical pearls. I hope they don't mind me copy-pasting today's pearl from non other than Amal Mattu:


"SVT is rarely, if ever, the presenting rhythm associated with an acute MI. As a result, physicians should not feel compelled to send troponin levels and perform rule-outs purely based on an SVT presentation. Instead, the decision to rule out a patient presenting with SVT should be based on whether there is a constellation of other concerning symptoms, exclusive of the SVT (e.g. if the patient presented with chest pressure radiating down the arm and diaphoresis, in addition to the SVT). Two recent studies confirmed that routine troponin testing in patients with SVT is extremely low-yield, and instead often produces false-positive troponin results that lead to unnecessary admissions and workups. In other words, mild troponin elevations may occur in SVT but they do not correlate with true ACS."
Say no more. This is... da shit!

Blogs

I have previously written a thorough post about blogs, podcasts and videocasts where you will find more details about the technologies themselves. Here I intend to introduce you to some of the big ones in emergency medicine, just to get you started. In my Stayin' alive post you will find a longer list of links to the 'rest of the best'.

If you're a newbie in the EM blogosphere, your first visit must be Life in the Fast Lane. It is an australian wondersite which is not only an awesome blog with regular news from the world of EM but also presents clinical cases and topics in thorough yet entertaining way to read. LITFL is run by EPs by heart and as such cuts out the crap, creating short and useful lists of diagnosis instead of Uptodate's style - ddx lists which can span pages. LITFL also has various databases for you to browse through like the ECG- and image database containing >100.000 free online medical images. Actually, LITFL is so huge that it would require a separate blogpost to review it but the fact that I list it here as the first blog you should try out is no coincidence. So get your eyes there right now, mate!

For updates in prehospital management you should read Cliff Reid's fantastic Resus Me (Australia). Then you can follow the latest interesting journal articles in EM from Emergency Medicine Literature of Note (Ryan Radecki, The University of Texas Health Science Center at Houston), a nice to read blog with the author's short and concise personal opinion of the articles he presents.

Most blogs have some interesting cases every now and then but nobody presents them in a more structured way, simple yet detailed as Emergency Medicine Forum does (Charlene B. Irvin, St. John Hospital and Medical Center).

One tip a day will make your vertigo go away - that is the motto of Michelle Lin (San Francisco General Hospital) who started the Academic Life in Emergency Medicine blog. Her well-applicable tips and amazing Paucis Verbis cards are what have made her famous in the blogosphere. Every now and then she has very nice posts on academics and IT in EM.

Emergency Medicine Ireland (Andy Neill) has an excellent mixture of article reviews and interesting cases, just the kind of thing you want to read over your first cup of coffee before the first trauma patient enters your ED.

As I've said earlier this is just the tip of the iceberg and I'd like to recommend that you put all these in your RSS reader - that will be your turning point in your learning curve. If you feel that's too much you could also try just reading the awesome and weekly LITFL review where they summarize what has been going on in the blogging community and shout out the most interesting stories. Too good to be true almost!

Podcasts & videocasts

If you feel ready for trying out the world of emergency medicine podcasts you are truly getting IT-hot. On the top of the mountain here is Free emergency talks which hosts a collection of podcasts (mp3s) from various major and minor EM conferences from around the world. Joe Lex is the mastermind behind FET and in in my opinion should be titled as today's Osler - such has the impact of his lectures been on my learning curve. Not only has he collected the podcasts but also tagged them with meticulous detail so that you can easily browse through topics, speakers or presentation years of your choice. I suggest you start trying out Amal Mattu's renowned cardiology updates. Stuart Swadron's "Chief complaint: Coughed up blood" also is a good starter (as well as most of his talks). Or Peter Rosen's (yes, the book author!) epic story about the first years of emergency medicine...

More in the spirit of podcasts (Free emergency talks is a collection of audio recorded lectures) is Scott Weingart's EmCrit, a well deserved winner of the "Best medical weblog" of 2010. Check out his teachings and you will see why.


To start you off in the world of video recordings I would hint you to try out HqMeded, there is simply none to rival their outstanding teaching modules and 4-5min short case presentations, mostly based on ultrasound findings that turned the tables.

If you want to have a big conference talk right in your living room try out All LA Conference, an amazing work of the genius Mel Herbert. It's totally free but even better are his other productions (require subscription), check out the link for a special post of video lectures for emergency physicians.
OK folks, this was a quick walk through the jungle of e-learning just to introduce you to this ever growing world our colleges are creating every minute. There's more to discover and for that I recommend you to read through my big collection of links in the "primary resources" posts.

Making it stick!

There is another side of the coin we haven't discussed and that is how to store everything you learn and keep organised for later retrieval. Our brains were not built for neither keeping or organizing such wast amount of information, you'll repeatedly frustrate yourself as you find out that what you learned just a month ago is gone!

What you need is a tool not only to store all your notes and documents but one that also allows you to easily browse and search through all your information. I will soon share my tips on this important topic so stay tuned!

Back from Kos 2011

I am back from the 6th MEMC at Kos 2011, what a great opportunity to meet enthuastic emergency physicians from all around the world! Although not the gigantic size of ACEP the quality was in no way inferior. I couldn't believe my eyes when sat listening to the history of emergency medicine and suddenly Joe Lex was up and speaking, THE Joe Lex! Being a little frontally inhibited I went up to thank him for his freeemergencytalks but he was in an instant surrounded by a crowd so I had no chance to explain him how i thought he was the Osler of our times by bringing all these wonderful lectures online and for free... next time Joe!

I gave a 20 minute talk "IT for emergency physicians", my first one on an international conference and was thrilled with the positive responses I got afterwards despite a little nervous first talk. I even got invitations to further talks so it will be interesting to see where all this leads to. It was extremely difficult to pack this broad topic into such a short presentation, so much was left out or slimmed while practising, leaving only a short introduction and a few examples of IT tools in work. For those of you who are here from the lecture I would like to tip you to try first to read through the "primary resources" from the top of the page, it contains all the links you were expecting in my talk and even more. Then there are a few of the topics in more detail dispersed through the blog archive and in the coming weeks I will be writing about practical use of Google Docs and e-laerning so stay tuned.

As promised, here are my slides and notes right from Google docs, I am planning to make an audio/speaker version of this in the near future so stay tuned. Unfortunately, as I head questions from the audience afterwards, I had to cut out my personal disclosure concerning Google so here it is:

"In the next session I will be talking a lot about Google, a corporation which has in only 10 years come to stand on the shoulders of the giants. I have no affiliations with Google but it is but honest to tell you that there are alternatives to Google’s applications like Microsoft's Live tools. I have tried some of these but Google’s simplicity and yet enormous capabilites of storing and retrieving my hundreds of megabytes of data has kept me there for years. As I often say to my friends, “Google is so much more than just Gmail”.

As I also explained in the talk, to survive the information tsunami requires simplicity - the multiple of websites available out there are too many to hold account on with different logins and ULRs. By using them correctly, the plethora of Google applications suffice most of my needs and there is only a single URL and login I have to remember. As for backup & security issues of having all your data in one place (also was asked about this) - there now is a tool, Google Takeout, which allows you to grab all your data from every single Google app to your computer, it will definitely help you sleep better. So actually - having everything in one place is a plus rather than drawback.

By the way, if you're new to Google Docs and want to try it out, here is a very short introduction to this powerful tool.


If you wan't to contact me you can use dabbi2000(at)gmail.com, you can also follow my Twitter account on https://twitter.com/#!/ZonOfThor

Information technology for physicians

Only 10 days more until Kos 2011: The Sixth Mediterranean Emergency Medicine Congress and my slideshow is finally taking shape. In Kos I will in a (all too short!) 20 minute session talk about "Information technology for emergency physicians".

We are living in new times where IT is becoming ever more important for the physician. Ignore it and your medical students will rival your medical knowledge and even your patients will remind you of your gaps. The modern e-patients are so much more informed today, knowing everything about their condition. The typical e-patient will seek the doctor to ask about the diagnosis, not the symptoms. The modern patient is 1000% more informed today than before. Are doctors 1000% more capable?

Every day we are being bombarded with information, wether we ask for it or not. IT skills allow the doctor to comfortably surf the information-tsunami instead of going down under it. This will be the take away home message in my talk in Kos where I will tell you about lots of tips and tools for being more IT-competent.


To warm up I'd like to show you this amazing video which gives us a glimpse of what might be the next thing - online conferences, right in your living room!

ps: I am curious to know if there have been any other talks about IT for physisicans, please tip me if you know of any!

The great imitators

You just sent home a patient with a weeks headache but no red flags? Or one with diffuse abdominal pain but normal lab tests? Are you writhing in your bed of remorse? Not sure if you just missed a zebra?

Well you are not alone. Everyone has missed their zebra in the ED. It feels a little relieving then that Wikipedia  has made a list of these diseases that you are about to miss one day. A list of red herrings. Know just a little about the small stuff and you'll have a slight chance of at least thinking of it in your next case of subtle symptoms. The confused patient who turns out to have lupus. Or the atypical parotitis revealing a hidden sarcoidosis. Being a little alert is all you need to do!

From the Wikipedia article:

"The Great Imitator is a phrase used for medical conditions that feature nonspecific symptoms and may be confused with a number of other diseases. Most great imitators are systemic in nature. Diseases sometimes referred to with this name include:

• Fibromyalgia
• Lupus erythematosus 
• Multiple sclerosis
• Sarcoidosis
• Infectious diseases
• Syphilis
• Lyme disease
• Nocardiosis
• Tuberculosis
• Celiac disease
• Heavy metal poisoning
• Addison's Disease"

Oh and also check my previous post about non-surgical causes of abdominal pain, highly recommended for emergency physicians scavenging for zebras in the snowfield.

The Android story continues

It's been a year with my Android and I'm still having a wow-momentry now and then. Unfortunately I haven't brought my discoveries to my IT/Emergency medicine blog and I have no good reason for that other than that many of the discoveries are not Android specific and could apply to other smart phones as well. Even the (in my opinion) little-enthusiased-to-iPhone. Smart phone is the new Swiss army knife and there are trillions possibilities to put them in use both in real life and as a physician, many which we haven't even seen yet. This as many other IT topics I will be discussing in my ´IT for EM physicians lecture´ at KOS in September.

I would though like to share with you a great graphical comparison chart (thanks www.tecca.com!) which compares the different Android OS versions. Many times I have Googled this, ending up in Wikipedias' detailed but a tad boring comparison tables. This one is a keeper!

I have never had an iPhone my self and so have no position to judge it as neither better or worse than Android. I can only say that I am 110% satisfied with the Android approach of everything-open and customizable and cannot imagine a day with a closed-system like the iPhone seems to be. Besides that, having Google as the backbone has also been one of the biggest benefits as their arsenal of applications and tools like Google Docs, Maps & Latitude, Calender, Gmail etc. is also another technology I couldn't be without and frankly - Google is on fire nowadays. Almost every day a new update or upgrade making their toolset even better to use. Inevitably, the Google apps will be a hot topic in my KOS lecture.

While we are at it I will also throw in a link from Tecca which compares Android and iPhone pretty neutrally. Though in the end I really don't think it matters which one you are using as long as you base your choice on what technologies you want inside your pone, not the brand.

 http://www.tecca.com/basics/android-vs-iphone-what-you-need-to-know/

A case of bradycardia - biliary disease or acute coronary syndrome?

A middle-aged man comes to the ED with one day history of severe pain in the upper abdomen. He is feeling increasingly uncomfortable and has nausea without vomiting. He appreciates his pain as VAS 7-8. On physical examination he is tender on palpation in the epigastrium, physical examination is otherwise completely normal. You get an ECG with no signs of ischemia but you observe sinus bradycardia at 37 beats per minute.

The lab results unfortunately return a hemolyzed Troponin-T but the LFT (liver functional tests) show ALP=3.2, GGT=8.8, ALT=1.4 and AST=2.3 (slightly elevated, suggesting cholestasis). Could the pain have a cardiac etiology?

Inferior MI and diseases of the upper gastrointestinal tract (gallbladder, stomach/esophagus especially) can present in very similar ways. Besides epigastric pain, patients commonly describe bloating and reflux-like symptoms due to vagal stimulation and gastric distension. Vagus stimulation explains why up to 40% of patients with inferior MI have sinus bradycardia (Bezold-Jarisch reflex). 1st to 3rd degree AV block is also common but how the mechanism of the AV node inhibition is not known.AST was for many years ago the only known cardiac marker. In the 1954 protocols for MI an elevated AST defined an acute coronary syndrome. Which in those days required hospitalization for bed rest mainly! It is a sensitive marker but highly nonspecific. LITFL (as usual) has an excellent article about the use LFTs, especially for the 'cut the crap' based approach of the emergeny physician
http://lifeinthefastlane.com/education/investigations-tests/liver-function-tests

All pain and physical stress, especially from stomach and intestines can potentially stimulate the vagus nerve and thereby cause bradycardia. The classical scenario is the elderly patient with gastroenteritis that comes to the ED after a syncope. The relationship between bradycardia and acute cholecystitis has actually been described previously and even given a special name, Cope's sign:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1795584/

Bradycardia in the case described above turned out to be caused by an underlying acute cholecystitis, the patient had an infusion and was admitted for emergency surgery. A new Troponin T was taken and turned out to be normal. A new ECG revealed normal sinus rythm.

Web applications are the software of the future

We all remember those days when Microsoft Office was installed from some 25 or so diskettes and once setup up it was a permanent version not to be updated for a few years. With the Internet, updating became a little easier but you still had to manually download and install. Now that the web-browsers are becoming ever more powerful the software world is being taken over by web applications. Don't be thrown off by the scary term, you most likely are already using web-apps already. Google Docs, Facebook and Twitter are one of many examples. A web application is not installed on your computer since it runs on the web. Instead of opening it from the Start menu you go to a URL and you have it up and running. With a login, it remembers your customized settings and content and hardly any data is written to the hard disk of your computer. You never have to bother if the application is compatible with your operating system or type of computer you have, the browser takes care of it all.

And so we are seeing more and more of web-applications and the classic software you remember installing from diskettes and CDs are now web-based. With the latest web-technologies such as HTML5 and 3D graphics inside the browsers a new era has started and there are no technological barriers for running almost any kind of software as a web-app. Recently audio and video editors have been appearing and Google's body browser (update: now Zygote body browser) is a pioneer for 3D applications as web-app, showing a glimpse of the future. Not even programmers would have believed five years ago that this would ever be possible!

Combined with "cloud computing", this is a gigantic leap in the IT evolution which will completely change the way we work with data. Your data and "software" configuration is accessible wherever you are as long as you're connected to the Internet and even if you're house burns down you can go to the neighbour and continue working with your documents. I like to call this the "mobile office" since you literally have your office desk with all it's tools and papers but in a virtual, electronic format which you can take with you anywhere you go or just open your documents on your mobile. Actually, since you do more than just editing documents and updating your calendar - it's more like having your desktop computer in your pocket. That is true IT power and can save lots of time and effort for the physician. I will later on write more about the mobile office concept and how I use it my self.

Ok, enough of this hallelujah web-app rant, you most likely are asking yourself what does this have to do with the emergency physician?

First of all, you are not any more dependent on a specific operating system. As said earlier, the web-browser is now the most important factor between you and the software (and this is why I hate hospitals that are slow to upgrade the web-browsers, for me it's literally like being forced to work with Windows 3.1). This gives you the opportunity to throw out old habits (I'll be less obscure, stop using MS Windows!) and give way for alternatives. Did you know for example that Linux is a well-established operating system which is free, more secure and stable than Windows  and uses considerably less resources like memory and CPU power - ultimately meaning a faster system. Since Linux is free of virus vulnaribilities it will give you that 10-15% of your CPU which antivirus software normally takes and you will never have to be afraid of crashing your computer because you accidentally pressed that "wrong button". There are many Linux variants but Ubuntu is in my opinion the best one for newbies and has amazed many previous Windows users. It takes only 10 minutes to install and if you're afraid of killing your other OS you can install it parallel to your Win/Mac and choose from the boot screen which one you prefer.

Secondly, your browser is now the bread and butter of your computer and you should really see over if you're having the best one and know how to use it properly. It is beyond the scope of this post to discuss the best browser out there but I can tell you that after years of trying out most of them, Google's Chrome is in my opinion leaving the competitors in smoke. It is fast, stable and incredibly easy to use, yet having very advanced powers under the hood. It's self-updating so you will never have to worry about compatibility or security issues. Add some extensions, you've got a F22 Raptor in your parking slot.

Finally, your valuable documents, pictures, videos and every single information you have collected through the years can now be electronic instead of heaps of papers in the shelves of your office. Imagine having all your articles you've read through the year in a single place, readable from home, work or even your mobile on the train while commuting. With an electronic marker-pen you've highlighted and made notes in those articles that have had the most practicable value to you and in only seconds you can have it back on your screen, just as you left it last time. Having all your emails and documents in a "electronic heap" means it's easily searchable... with a single click you can search through everything you've read or written for the past years. A lost login to the local EMR system, your impersonality notes about ECG reading or just the number of your bank account - it's all right there at the tip of your finger!

You want to relax after work and listen to David Bowie's soothing 80s music? Listen to it at Grooveshark.com and you can search through terabytes of online music and play it right from your screen. If you've created an account you can even play that "dinner playlist" you just created the other day to bring up good memories. You have an ECG which needs to be edited to erase patient ID and resize. Open pixlr.com - an insanely amazing photo-editor which does most if not everything that Photoshop does, completely free of use! You always wanted to try a 3D editor? It's yours if you just click this link! Oh and you have a video that needs the final touch but don't have your laptop with you? Don't worry, you have several to choose from. Oh and they're also free! If you need to create a video-tutorial of something you are doing on your computer, say using your local EMR - guess what, there's a webapp for that too! And if you ever get suspicious, you can even run a viruscheck from a website!!


You get my point. Start building up your collection of web-apps, it is the true beginning of being an IT competent doctor. This post hopefully inspires you, the rest is up to you. In my next posts I will tell you about the Google Apps and the importance of simplicity aka "cockpit approach" to web applications. For me at least, it has stepped up my learning curve more than any other modality.


Still confused? Check out these ultra short videos about webapps:

The Toastmasters´ podcasts

In preparation for giving a talk about "IT for emergency physicians" in Kos in september I stumbled upon a great podcast site, The Toastmasters Podcasts. The Toastmasters club needs no introduction but in case you haven't heard about them:

"Toastmasters International (TI) is a nonprofit educational organization that operates clubs worldwide for 
the purpose of helping members improve their communication, public speaking and leadership skills..."

Their podcasts are simply awesome and touch everything you have to know to be a good speaker. Preparation and training is the most important thing you do if you don't want to end up standing in front of your audience with a crimpled tongue and your head full of cotton. Now matter how much you've worked on your slides and notes - if you show up untrained, you WILL fail! So enjoy these great and free podcasts where they feed you full of preparation tips.

The shocked skin - livedo reticularis or cutis marmorata?

A patient in shock will often have a skin-pattern that is hard to forget. This pattern is also seen in the last hours of a moribund patient and almost always post-mortem. "Mottled skin" is the insider slang; it is commonly described as cold, damp/sweaty, pure white with small patchy islands of purple/pink spots in between. This skin pattern, together with the clinical picture, should bring the doctor to the attention of a true emergency where the patient needs immediate care. Physiologically this phenomenon has been explained by peripheral vasoconstriction, an effect of rush of catecholamines in the blood. The body is in a shocked state and strives to move all volume from the periphery to central spaces. If the patient is awake he will most likely be at unease, confused and agitated because of poor CNS perfusion, catecholamines and even pain.

Initially, the purpose of this blogpost was to entertain the reader (hopefully emergency physician) with the one and only truth about the "mottled skin" since it is a common and frightening sight in the ED but vaguely defined. However, it appears that there is no concrete truth in this case, even major sources (Harrison's online, Merck Manual) are silent as the grave. In the end I found some explanations in on of the two holy bibles in emergency medicine, Rosen's emergency medicine, though in the pediatric section (the other is of course Tintinalli's). I want to belive their description also applies to adults:

Compensated shock can be recognized by the presence of pallor. A pale child with a rapid heart rate should always be considered to be in shock until proved otherwise. As cardiac output is further compromised and perfusion to vital organs is decreased, the skin may become mottled. Mottling is manifested by areas of vasoconstriction and vasodilation in a random pattern on the skin. It reflects loss of small vessel integrity and may be similar to what is seen in vital organs during multiple organ system failure. Mottling is usually an ominous sign. It is important to not confuse cutis marmorata with mottling in young infants [...]. Cutis marmorata is a lacy marbling of the skin caused by vascular instability. It is a normal finding and is commonly seen in infants in a cool ambient environment.

Cutis marmorata

is sometimes mentioned along with shock but there are other more common differential diagnoses such as decompression sickness, normal (cold) response in young children and a congenital variant (CMTC). All indicate instability in the vasculature (vasospasm/dilation). The patterns are unfortunately not uniformly defined as seen in the pictures on DermAtlas and NEJM.

Livedo reticularis

is also connected with shock, as in this case in BMJs "Images in emergency medicine" series. It confuses however my view of the phenomenon whereas other sources describe livedo as a common pattern of various well-defined, mostly autoimmune, diseases ranging from benign to acute ischemia of the extremities. The skin pattern is sharper than cutis marmorata and the morphology more reticular, as the name indicates.

So after all the browsing I unfortunately didn't come to any intelligent conclusions; for "mottled skin" in the shocked patient, there is no good definition or specific description and differentiation from other similar symptoms pictures of more benign origin. What is clear (as before!) however is that this is a pattern that all emergency physicians must be aware of as it commonly indicates a disaster on its way.

Discussion forums, part 2

Not so long ago I hade some thoughts about a common discussion forum for emergency physicians all around the world. The idea came more from the need than "just because I can do it".

Emergency medicine is a very young specialty in Scandinavia and as such we have a lot to learn and discover. Although my ED can proudly claim to be one of the first and most developed in Scandinavia - we still are no more than 30 or so young and enthusiastic residents but without the backup of emergency medicine specialists who've been there for ages and "seen it all". So we have many questions and ponders over clinical and practical aspects of the ED which require that extra experience and cannot be answered internally. Comparison of treatment methods or approach, types and use of ultrasound devices, prehospital involvement just to name a few examples - a discussion forum would be truly useful for sharing thoughts with colleges abroad and having those special questions answered or at least discussed.

Some might have thought Facebook is all we need and surely it would be sufficient if everyone was familiar and comfortable with it's privacy hassle. It turns out doctors are paranoid as cats in the bathtub and I've never been able to engage projects with FB because of this, frustrating as it is. Twitter is another option and with the use of a selected hash-tag, say #em-forum, it should be easy to setup a centralized, simple to use platform. But tweets are limited to 140 characters only and discussions are open to the whole Internet. And then too many doctors don't even have a Twitter account, except for Dr. Bailey who just jumped onboard.

I exchanged my thoughts with the ever hyperproductive LITFL guys and they reminded me of http://www.doctors.net.uk which is essentially a social network (Facebook like) platform where registration is moderated so that there are only doctors signed in. I must admit, I haven't been there for a while but the mere idea of persuading thousands of emergency physicians to register and try it out gives me chills all the way from brainstem down to cauda equina. I actually tried once using the free-and-easy-to-use Ning social-networking platform to engage my colleges - they liked the idea but signup/login treshold and a miniscule learning curve was still enough to kill it in birth. Doctors are busy, conservative (just a polite way of saying IT-lazy) and generally exhausted - everything new needs to be dead simple, easy, ready-to-use and again; dead simple.

That leaves us with only one option, email. Every doctor has an email and reads it on a daily basis or so. A server backup-ed, email based postlist system with functions to moderate content and members would be absolutely necessary. Members would want to have an option to login to change their profile and settings (receive immediately or digested content) and even go back in time and read older posts in the archive. Members should be able to see each others and even contact them individually. The system should still be closed for the public, that is - open for special registration/invitation only.
Is this starting to sound like Google Groups? Well, it is. GG is the only system I have managed to use to successfully get together a group of doctors and believe me, I've tried a lot of platforms.


Besides being a tip for you if you wan't to engage your colleges at work for off-work discussions, this will be my attempt to make a unified discussion platform for enthusiastic and alike emergency physicians all around the world. Now that I have colleges in USA, Australia, Iceland, Sweden and UK - this surely has a potential for multicultural emergency medicine discussions. So if you feel interested please feel free to invite yourself at
 https://groups.google.com/group/em-physicians

We'll see what this expirement leads to!

Dr. Bailey does the Twitter

My wife told me yesterday about an interesting scene in the last episode of Grey's anatomy. It turns out Dr. Bailey was Twittering in the OR for the sake of getting assistance from her social-network. As expected she was met with sceptism and disbelief from the chief who finally though got the catch and accepted this new technology. This short clip says all there is to say about Twitter - and social networking in general. It is bound to make a HUGE impact on the way we practice!


I wonder if the script was based on a true story where a college had difficulties with a patient in severe hypertensive crisis but got help from Twitter?

Google custom search to search all your blogs and resources

Most doctors have a set of favorite websites they have become familiar with and prefer to search when immersing in a clinical topic or issue. Medscape's Emedicine is one of these, I find my self repeatedly Googling a topic and adding "emedicine" to search their site specifically. As most of you have found out, Googling medical topics commonly leads us to completely irrelevant sites like patient information or even veterinary sites. Just try 'ileus' - you'll get tons of recommendations on how to treat a horse with no bowel sounds!
While everyone of us searches the web for clinical information every day or so I am amazed to see how little physicians bother about the actual search tools or using advanced search queries since these can significantly alter the results in a positive way. It's pretty much like scavenging the ocean floor when looking for birds.

Google has a special "site:" operator to search a particular webisite (URL) or even part of the site only. This will give us even better results than the above mentioned query;
 "ileus site:emedicine.medscape.com"

will return results only from Emedicine. This way you can use the power of the Google search engine rather than the sites' own.

You can actually add more site:... operators to search a group of websites but that's making things a bit complicated isn't it? So what if you could search a predefined group of sites only?
Well, Google custom search is exactly that and even more. It's one of the excellent Google tools and as such free and uses your Google account to store your predefined sets of selected searches. Yes, you can define not only one set but as many as you wish. I have been using a "medical community" group where I search my favourite emergency medicine blogs (the 'blogosphere'), perfect for finding my colleges' personal experience and opinions or even updates on clinical matters. Then I have a "basic medical resources" where I have included Emedicine, "Merck manual" and similar webs when I want to do some "back to basics" digging into the medical knowledge.