Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org.
EMCrit 297 – EVARs, TEVARs, and Endoleaks – Oh My! with Ani Aydin
EndoVascular Aortic Repairs are a game changer in patients with AAAs. Add a T and you get a TEVAR for the treatment of aortic dissections. Despite the amazing advances that these devices represent, they are not without problems.
Recently Done Operation
Look at the Access Site in the groin. These devices require enormous access in the femoral vessels. Search for pseudoaneurysms, dissection, thrombosis, or bleeding.
Kidney injury both from operation and all of the imaging that goes along with it
Leaks through or around the graft into the original aneurysm.
Get imaging. Don't get ad hoc imaging. They need specialized CT angiography of the chest and abdomen with both arterial phase and delayed venous phase. You really want to work the scan parameters out ahead of time with your radiologists.
* Type 1: Failure of complete apposition to vessel wall (1a is proximal, 1b is distal)
* Type 2: Retroleak - Back flow through a vessel
* Type 3: Graft torn or ruptured
* Type 4: Porosity of the graft
* Type 5: Unclassified/Who Knows?
from UW Emerg Radiology
Type 1 and Type 3 needs immediate surgical intervention
for the others, Aortic dp/dt control just like a dissection until you get in touch with Vascular
Thrombosis and Embolus
These pts can through clots to their distal vessels
Look for arterial clots and for mesenteric ischemia
Reach out to the Patient's Vascular Surgeon
anytime someone has any issue with their EVAR, call early!!!!
Other Great FOAM
* EM Docs on EVAR Complications
Now on to the Podcast...
Podcast 180 – On Argumentation, Fallacies, and Twitter Misery
Anatol Rapoport’s Rules: How to compose a successful critical commentary by Daniel Dennett
* You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.
* You should list any points of agreement (especially if they are not matters of general or widespread agreement).
* You should mention anything you have learned from your target.
* Only then are you permitted to say so much as a word of rebuttal or criticism.
Step 1 is analagous to steel-manning, aka the principle of charity. This is to avoid the act of straw-manning.
from the amazing book, Intuition Pumps and Other Tools for Thinking
Paul Graham's Hierarchy of Disagreement
for more on this
What would it take to Change Your Mind?
Ask your subject, what would need to change for them to change their belief?
More questions to ask yourself
* 4 Maxims that can serve as a guide-map to conversation and argument
* Some tips for evil debate
* Avoiding Logical Fallacies
* More on logical fallacies
* How to craft a good argument
The Book to Buy
An Illustrated Book of Bad Arguments
Ten Commandments of Rational Debate
The ones I see infecting FOAM debate again and again
Three logical fallacies, two seen universally and the other unique to medicine. The former two are the status quo bias and the bad-bayesian bias and the latter is Benefit/Harm Evidence Equalization.
Status Quo Bias
Thinking b/c we do things a certain way, there is evidence behind this way
See Rich Carden's discussion o...
Podcast 179 – An Interview with Gary Klein
Today, I am joined by my friend, Mike Lauria, to interview Gary Klein, PhD. Dr. Klein is a masterful cognitive psychologist. He is known for many groundbreaking works, including: the Recognition-Primed Decision (RPD) model to describe how people actually make decisions in natural settings; a Data/Frame model of sensemaking; a Management by Discovery model of planning to handle wicked problems; and a Triple-Path model of insight. He has also developed several research and application methods: The Critical Decision method and Knowledge Audit for doing cognitive task analysis; the PreMortem method of risk assessment; the ShadowBox method for training cognitive skills. He was instrumental in founding the field of Naturalistic Decision Making.
Sources of Power
This is the one that got Mike and I started as Klein Fanboys
Streetlights and Shadows
The absolute best compilation of Dr. Klein's decision-making concepts that are directly applicable to medicine
Seeing What Others Don't
Next up on my reading list
Recognition Primed Decisionmaking
Wikipedia Link for RPD
Sites and Links
* Dr. Klein's Company
* Shadowbox Training
Articles Mentioned in the Show
* Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009 Sep;64(6):515-26.
* Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches. Journal of Cognitive Engineering and Decision Making
Additional Related Stuff
* Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.
EMCrit Podcast 172a – The Mind Palace?
The mind palace, also known as the memory palace or the memory theatre, is something I want badly! Ever since I read the incredible book, the Art of Memory by Frances Yates, I have dreamed of building a mind palace. But in medicine, we should be able to externalize the palace--in fact, we must! The method of loci will not suffice.
Technology should surely have advanced to the point where this is simple--the programming requirements are trivial.
My current mind palace is at CrashingPatient.com. It is quite good, but not perfect.
We need a place to store all of the literature, books, and internet posts/media we feel will be valuable. The storage must be durable (if an internet site goes down, the work remains). If we lose our paid access, we retain the full text of the literature.
The medium should allow comfortable reading of the literature, viewing of the media, etc.
Should be immediately accessible offline or online. Should be firewall resistant.
Ease of Commenting/Summarizing
Need to put the take-home message somewhere. Additional thoughts, new findings. Really two separate things:
* We need the ability to comment on, by which I mean literally on the paper (i.e. scribblings, marginalia, highlighting)
* But also the ability to summarize a Topic and add those papers as citations in a way that would link to the scribbled on paper
Ease of the Edit
Front end editing
Or at the very least, immediately exportable to open source
All information should be easily retrievable with logic, operator, and fuzzy logic based searches
Option to Publish
Should you want to share your memory palace
The Mind Palace Cycle
* Storage for to-be-read/to-be-viewed
* Publish or Protect as Desired
image from memorise.org
Want to read more about memory?
The Art of Memory, mentioned above, is amazing--but oh so dense. For a lighter, contemporary read:
Some additional requirements/desires:
* Self-Updating TOC as frontpage (see crashingpatient.com)
* Search must be browsable by either google or a plug-in and updates in real time
Podcast 171 – OODA Loops
My keynote lecture at SMACC-Chicago was on OODA loops and the supremacy of System I for resuscitation. The lecture was plagued by AV-wankers to the point that I thought the talk was a shambles. I am rerecording the lecture here for EMCrit and the SMACC site. I hope you enjoy--SDW.
The OODA Loop
OODA Loops and John Boyd
* I'm loathe to link to this, but this probably the most accessible description of OODA loops and Boyd Philosophy
Protocols May Cause Harm
* Protocols for the OODA Loop Trilogy
Why I Hate ATLS
* Archaic Trauma Life Support
Guidelines are not for experts
* Conditions for Intuitive Expertise by Gary Klein
* ED Cognition by Croskerry
More to Read and Watch
* Physiology Inside the Loop
* More on OODA
* Klein Ted Talk
* Klein Strategies of Decision Making
* Croskerry Lecture Thinking Straight Lecture from SMACC
* System 1 vs. System 2
* All things John Boyd
The Book to Buy
Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making
Ugggggghhhh. I couldn't see my notes while rerecording and I said Boyd was a Navy Pilot, when of course he was air force. And it was the air force that has reportedly not embraced his work. Sorry Navy. Thanks, Jim!
* From SMACC Chicago
Audio Only Version
* Audio-Only OODA
EMCrit 296 – The French Connection, Part 1 – Resuscitation Geography, Logistics, & Ergonomics
After my recent Resus Room Readiness post, my buddy James got in touch with me wanting to do this episode. I said frack that, we can't do an episode, there is too much goodness in the French brain, we need a series. This is the first episode in a new series with an amazing Emergency Medicine Doc and Innovator, James French.
James French, MD
Dr. James French was born to a father that was an incredible engineer and tenacious inventor. James’ earliest memories were working with his dad restoring vintage motorcycles which sparked his fascination with fixing things. When James was 5 years old he went to watch the film “Superman” with his dad. It turned out they knew Christopher Reeves from the flying club that they went to, so they actually knew superman while he was learning to fly. James attended many Emergency Departments in the years after as it turns out that no matter how hard he believe you can fly or whatever machine he invented, gravity always won.
Whilst studying for a science degree he realised that training in martial arts was a partial antidote to not being able to sit still or focus on one task and has trained in martial arts throughout the majority of his life.
In 1995 James started medical school in Southampton, England. In 1997 at a local kung-fu club he met a guy called Dr. Cliff Reid who was a resident or registrar in Emergency Medicine. They immediately became friends. Whilst at medical school James would shadow Dr. Reid when he worked in the ED, particularly at weekends . They constantly exchanged ideas about resuscitation, psychology, meditation and of course martial arts. Cliff later stated openly on social media that James saved him from a residency system that was breaking him. To outsiders it was obvious that the “saving” was a two way street. James’ passion for resuscitation and education comes from Cliff.
James graduated medical school in 1999. Whilst driving to work as an intern in 2000 he was first on scene at a fatal road traffic collision. Trying to render aid to multiple trapped and dying casualties, with no formal training in prehospital care was a formative experience. He started working with the Magpas Air Ambulance System (www.magpas.org.uk) as a volunteer in 2003. The training course featured multiple days of simulation based medical education, a competency based curriculum and was probably a decade ahead of its time and was lead by the legend that is Dr. Rod Mackenzie. Influenced heavily by the aviation industry and the military Rod and James invented the first RSI kit dump and RSI checklist in about 2006. James continued to work with Magpas in PHEM until 2012.
In 2009 James started working as an attending in Addenbrookes Hospital, Cambridge and was given the task of selecting and purchasing all of the clinical equipment and for a new Trauma Center. Influenced heavily by a very strong department of clinical engineers lead by Prof Paul White, James realised the necessity of applying principles of from EMS, ergonomics, lean and clinical engineering to resuscitation practice.
In 2012 James moved to Canada to work in Saint John, New Brunswick. Whilst in New Brunswick he chaired the trauma research subcommittee and lead an interprofessional team to establish a province wide simulation system for trauma education. In 2017 James met Dr. David Elias, who is an Emergency Physician and highly successful medical entrepreneur,