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A Journal of FOAM??

Over the past couple of weeks myself and others (Michelle Lin, Todd Raine, Lauren Westafer, Minh Le CongJavier Benítez , Simon Carley, Nadim Lalani, etc!) have tweeted, mused and, in the case of Michelle Lin, even experimented with the idea of peer-review for FOAM. My thoughts are summarized in blog posts here and here. Those posts, along with Todd Raine’s Storified version of the twitter conversation and Michelle Lin’s post on her experiment provide a reasonable overview of the conversation so far.

To summarize briefly in black and white: FOAM skeptics argue that it lacks peer review and therefore has no quality control. FOAM supporters argue that its peer review is crowd-sourced through comments and traffic (good content gets linked to, bad content does not). Michelle Lin created a feedback form for her posts on ALiEM that allowed peer-review of the posts. Unfortunately, while the posts were of high quality (in my opinion) and got view counts that my site daydreams about (as does everything on her high-quality site), few people filled out the forms. While there was much speculation about why this might be (form fatigue, took too much effort, nothing controversial was said, etc), the review mechanism was not as robust as one would hope.

I was disappointed.

Then this conversation happened:

Deirdre Bonnycastle ‏@Bonnycastle
Thinking about Scholarship of Teaching and how contributing to Free Open Access Meducation is not recognized as scholarship #FOAMed #meded

Brent Thoma ‏@BoringEM
@Bonnycastle
I think some bloggers/podcasters are recognized by their institutions for their contributions, yes? @M_Lin @sandnsurf @emcrit

Mike Cadogan ‏@sandnsurf
@BoringEM
@bonnycastle @m_lin @emcrit …still fighting, but definitely more tolerated now. Not hospital or Uni supported, but dept support

Michelle Lin ‏@M_Lin
@boringem
@Bonnycastle @sandnsurf @emcrit I get variable support vs tolerance. Ratio of support to tolerance increasing over yrs. #babysteps

Deirdre Bonnycastle ‏@Bonnycastle
@sandnsurf
@boringem @m_lin @emcrit I’m griping because uni is pushing for more scholarly work without recognition of SM.

And it got me thinking along another path.

Certainly, the observation that FOAM is not recognized academically is not new. Skeptics would argue that it shouldn’t be recognized using the same refrain they use to criticize it: “It’s not peer-reviewed” they cry. Peer-reviewed medical journals would generally not consider publishing any FOAM content because it is already available freely. However, there are exceptions. For example, Open Medicine and the Public Library of Science, perhaps among others (I didn’t do much of a search), are free, open-access online journals that peer-review their content.

Could FOAM do the same?

During the twitter conversation on this topic Minh Le Cong suggested peer-groups review FOAM content. Why not a peer-review group under the auspices of an online open-access journal? One that, rather than accepting manuscripts and reviewing them, flipped the journal paradigm on its head and picked through the best FOAM published each month and peer-reviewed it. The author could be contacted and asked if they would be interested in having their content reviewed for publication in the currently non-existent Journal of Free Open-Access Medical Education. If they agreed, an editorial team would comb through their contribution (be it a text review, procedural video, podcast or anything else [podcasts might be difficult to edit…]) and provide feedback along with acceptance, suggested changes, or rejection.

Why would this be good?

It would bring peer review to some FOAM content
It would provide the best FOAM to the masses of skeptics with quality control
It would support the academic careers of those creating the best FOAM content by allowing them to cite some of their online work
It would promote publication-worthy FOAM and the authors that produce it
It would utilize the work already done through crowd-sourced review to find the best work. This would also reduce the editorial burden as only great work would be reviewed
It would encourage FOAM content producers to create publication-worthy content
It would maintain the free open-access spirit of FOAM
It is better than what we have now

Why would this be bad?

The journal would be republishing content
I am not academically experienced enough to know for sure, but I suspect open-access journals are less prestigious than other journals, decreasing the benefit to the author
Not enough content could be published to make a difference to the potential academics that put tons of hours into this
Academic rigor would take the fun out of FOAM
We’d be giving in to the critics
Multiple other reasons I’d love you to tell me about

Conclusion

Having written this out I’m not even sure that I want to post it. Creating a FOAM medical journal is out there in a way that could make me the “crazy, unrealistic FOAM resident with stupid dreams that everyone points at and laughs.” Regardless, I look forward to the feedback and the possibility that someone will read this and come up with an idea that helps FOAM to grow in the eyes of the academic world from a rambunctious toddler into a polite teenager.

Please encourage my posting and help to develop this conversation by leaving a comment, tweeting about it, retweeting tweets about it, following me on twitter @boringem, following my blog through e-mail (right column) or following my blog through an RSS feed (top right corner).

Next week I promise to quit posting about the Canadian residency match and FOAM and get back to the boring medical topics that are the original purpose of this site. Thanks so much for reading!

Brent Thoma @boringem

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CaRMS Game Time: The Interviews

This is part two of what I have decided will be a trilogy, kind of because it fits nicely with the topics, but mostly because Star Wars convinced me that trilogies were full of win. See: CaRMS Pregame: Preparing for the Interview and, after I write it, CaRMS Postgame: Rank-lists.

There are generally three parts to the interview: the social, the tour and the interviews. Once again, I can speak only to the FRCPC-EM tour because that is the one I was on and, from what I hear, the interviews for other programs can be very different.

The Social

Generally these are held the night before the interview day that is “owned” by that school (as discussed in my last post, that may not be the only day a program is interviewing). They are most often held at a pub and offer greasy appetizers and free booze. Occasionally a program will get creative and go bowling or go baller and buy supper. The Social is an opportunity to meet your fellow applicants, the staff, the residents and the PD’s in a more casual environment.

What to wear:

One of the biggest applicant stressors seems to be one that matters very little: what to wear. In general, I’d say that I don’t think anyone actually cares what you wear, but I’ll offer two caveats to that.

-If a program specifically tells you what to wear, you should probably go with that. They may be having their social somewhere snazzy. Fashion.about.com is infinitely more qualified to interpret the “dress code lingo” than I am (I wear scrubs to work every day – I seriously don’t care). If they don’t, I’d say business casual-ish is fine although erring on the side of business formal generally won’t hurt you and would certainly be preferable to being underdressed.

-Don’t wear something really weird. Everyone has heard stories of applicants showing up dressed less-than-professional. While that slinky sundress might look great on you, if it’s the middle of winter in Canada it probably won’t make a good impression.

There are reasons that you will want to stand out on the CaRMS tour, but what you are wearing probably isn’t one of them. Play it safe.

What not to do:

I joked about this in my last post because it seems so obvious, but I think I should still reiterate: don’t get drunk – accidentally or on purpose. While almost all of the socials will have open bars, getting tipsy is very unlikely to work out in your favor. Sure, maybe the residents will think that you’re cool because you had a bunch of drinks with them and stayed out super late. That might work out well for you. It also might make you look like a doorknob in front of the PD. Even if it doesn’t, good luck getting engaged in your tour the next day or rocking your interview. If you’re one of those people that is still young enough to pop out of bed bright-eyed and bushy-tailed the next morning while the rest of your classmates are stumbling towards the bathroom, remember that you likely still have a lonnnng interview tour in front of you and I guarantee that you will be exhausted by the end of it. Don’t waste yourself on this.

The social is generally not part of the interview that is going to make or break you on the rank list, but it can bump you up slightly or down a lot depending on how you interact.

What to do:

Meet the other applicants – Please don’t look at these people as your competition, it is not worth it. While in a way, they are, remember that each of them can only take a single spot. Even if one of them does beat you somewhere, once they pick where they want to go they’re not going to be competing with you anymore. They can only take one of the 68ish CMG spots. Even if you go into this with that perspective (which you shouldn’t because it’ll make you look like a jerk), I’m quite confident that you’ll come out of it with at least some good acquaintances. It’s hard not to with such a grueling tour. On the other hand, making friends with them is great for so many reasons.

-You’ll be seeing them around a lot at different interviews
-If you match to the same place you can be new friends
-You can save money by car pooling with them
-You can save money by sharing rooms with them
-They’ll be your colleagues for decades
-They’re safe people to hang out with at the socials and the pre-interview when you don’t know anyone else

Meet the residents – This social is your opportunity to get the inside view of the program if you weren’t able to do an elective. Talk to the residents about what they like, what they don’t like and what is changing. Observe how they interact – dynamics will range from “happy family” to “we do our own thing” and chances are that you’ll fit in with one of those better than the other. Talk to them about their fellowship plans. Ask if they or any of the staff are working in any of the areas that you are interested in.

Meet the staff – See how many of them came to get a rough idea of how engaged the faculty are. Observe how they interact with the residents. Find out what their areas of interest are from the residents. If there is anyone there with an interest similar to your own, go introduce yourself to them and ask them about it! There’s nothing an attending likes more than to meet a prospective resident that is as pumped about their obscure little area as they are.

Introduce yourself to the PD – This is a tough one. It’s always easy to pick out the PD at these parties because they are the ones standing in the middle of a semi-circle full of eager medical students. That makes them hard to talk to. However, I still think you should go and introduce yourself to them. Take the middle ground when you do: don’t stand around in the semi-circle for hours on end attempting to force conversation, but don’t avoid them all night either. Both are kind of weird.

The Tour

Initially, these are very exciting. By halfway through I found them painfully boring. Unsurprisingly, most hospital’s and ED’s look pretty alike (although Ottawa’s ED’s and McGill’s Sim Lab are totally baller) and when you’ve seen one helicopter landing pad, you’ve pretty much seen them all. Still, its nice to see the facilities that you’d be working in so its a pretty obligatory part of each stop.

What to wear:

This time it’s pretty easy. If it’s before your interview, the same clothes that you wore to your interview are fine. If it’s after your interview some students change into something more comfortable. I think that this is fine, but lulu pants are probably pushing it.

What not to do:

Stay off of your freaking cell phones! A quick glance every now and then is fine, but nothing says “I don’t want to match here” more than texting constantly. Like the social, you generally aren’t going to make or break your chances on the tour, but your interactions could bump you a few spots on the program’s rank list or drop you a whole lot if the residents DNR (do not rank) you.

Lesser extremes of disinterest include not asking any questions or looking interested in anything. Even if it is the end of the tour and you have no desire to match at the program you’re interviewing with (why are you there then?), at least act interested. Sometimes CaRMS doesn’t go like you expect and, even if you’ve got 10 interviews, slacking on the ones you’re less interested in might leave you unmatched if your “sure thing” doesn’t work out like you thought.

What to do:

Consider this a visit to somewhere you’re considering moving, because it is. Check out the facilities. Ask questions about both the program and the city. Ask where residents live and how they get to the hospitals. Ask how much housing costs and if they generally buy or rent. Ask yourself if you think you could be happy there. This may be the last time you see the place until you move there in June.

The Interviews

The interviews most often consist of two or three small panels that include a mix of residents, physicians and PD’s. The format didn’t vary a lot from site to site when I went through a few years ago, but I know that there has been a lot of experimentation with other models in other specialties. The number of positions/applicants also seemed to affect things. For example, Toronto and Ottawa interview tons because they have so many spots, BC interviews less applicants/spot because everyone wants to live there, there may be more than one set of interview rooms (ie Toronto) or everyone may get interviewed by the same people (ie Dalhousie). I don’t know of a lot of publications on the EM interviews, but Dr. Bandiera (Toronto) did publish a paper a few years back that describes the system that Toronto (and possibly McMaster) has used in the past. You can read it here for some insight into what the interviewers at those sites are looking at, but remember that it is a more formal interview than some of the other programs have.

What to wear:

Business-formal (ie suits and ties for the guys, business suits or blouse/skirt kinda deals for the girls) seems to be the safe way to go. Once again, looking sharp is great, but you’re playing with fire if you want to get crazy. Yes, everyone will remember you with your baby-blue suit and bow-tie, but probably not for the reasons you’d like. I’m sure that there are people that can pull that kind of thing off, but I’m not one of them and I don’t think this is time for you to experiment.

What not to do:

Unfortunately, you can’t really teach this stuff on a blog. Certainly, there are an infinite number of possible blunders that could drop you, for example:

Interviewer: Tell us about a weakness.
Applicant: I’m bad under pressure.
Interviewer: Okay. Err… Yep. You definitely are.

However, there’s not much anyone can do to help you if you say something like that. Generally, the interviewers are quite nice and want you to have a good experience – it’s hard to see it from your perspective, but at some point you’ll be ranking our programs and we want the applicants to like us! Horrible interview stories don’t help.

If you get thrown a bizarre question (ie – if you were a fruit, what would you be and why?) take it in stride. Come up with anything in a good-natured way and you’ll be fine. That didn’t happen a lot on my tour and I wasn’t truly sure what they were trying to assess with those kind of questions (I really don’t think it’s that similar to the quick-thinking required by our specialty), but there were a couple.

Just to allay any concerns, there was no medical expert content on any of my interviews.

What to do:

Be prepared. Know the answers to the common questions like the ones I mentioned in my previous post. Have educated questions about the program (they generally allow you to ask at the end) – the residents on the social and tour are great people to get an idea of what would be good to ask. Don’t be too nervous. Be passionate and present. Again, you can’t teach this stuff.

However, one thing that I didn’t mention in my last post on preparation was how good of an idea it is to rehearse before your first few interviews. No, you don’t want to sound like a broken record (although you probably will by the end because you’ll have answered the same questions a ton of times!), but sometimes your solid answers to questions fall apart when you try to say them out loud for the first time. Additionally, an observer might be able to point out an aggravating habit that you have in an interview that you wouldn’t notice yourself (ie saying “like” every 3rd word) that you can work on before your interview. It might help to have a trusted mentor or someone that you don’t know at all play this role (if possible) to make it less awkward.

Conclusion

That is all for part two of the trilogy! Stay tuned for the final chapter sometime later this week.

If you found this helpful, please support my blogging. I unfortunately have no way to accept cash, but can be paid in referrals. E-mail it to your classmates, follow me on twitter @boringem, retweet my posts on twitter, sign up to get an e-mail each time I post (right column), follow my RSS feed (top right corner), and check back regularly.

Brent Thoma @boringem

CaRMS Pre-Game: Preparing for the Interview

It’s that time of year again. The references are in, the applications are complete, interviews have been accepted, flights are booked and medical students across Canada are preparing themselves for the rigamarole known as CaRMS that will determine where they will be living for the next 2-5 years and what kind of medicine they will be practicing for the rest of their lives.

It’s a bit stressful.

As I wrote about interviews I realized I could take these posts in two directions. I could speak broadly about residency interviews in general (ie – don’t get drunk at the social), or focus in on the specifics of what I know: the EM interviews for the FRCPC programs in Canada. I decided to go with the latter to allow for specifically pertinent advice. As a result, this will be less applicable to lots of people, but hopefully very relevant to the applicants that I will be meeting in a few short weeks.

In my 2nd post for the “Mentorship” section I hope to help you de-stressify by offering some advice on preparing for the tour. I had hoped to also offer interview advice in this post, but due to length and fatigue, I have decided to split it into two. This post will be followed by one on the interviews themselves sometime next week.

My perspective on this has been formed by my experiences. I was an applicant on the EM interview tour in 2010, interviewed in 2012 and helped to create rank-lists in 2011 and 2012. Keep in mind that it is my perspective and some people are bound to disagree. Try to get as many perspectives on this as you can so you can develop a well-rounded view.

Onto the advice:

Pre-game: Preparing for the Interviews

1 – Know your application

Anything that you put on it is fair game to ask you about so you better be able to talk about it! In many of the interviews you will have an opportunity to steer it towards things you want to talk about to some degree, but sometimes an interviewer will be very interested in a particular thing about you and ask you about it. Be prepared!

2 – Know yourself

Cheesy? Hell ya. Important? Very. Things to think about:

Tell me about yourself.

A frequent opening to the interviews, it’s actually a hard question. Recognize that it is your opportunity to play some role in directing where the interview will go because the things you bring up here are more likely to come up again. It’s an easy question to ramble on about so be succinct. Please don’t tell us your entire life story! I think an “elevator speech” (google it) would be appropriate.

What are your strengths and weaknesses?

For real. Doing that thing where you name a weakness but then talk about how it’s really a strength (ie – sometimes I take on too much, but look at my application, aren’t I a total rockstar?) is total BS. We all have weaknesses, if you don’t know what yours are you need to work on your insight. Similarly, be proud to tell us what you’re good at – we’re giving you the opportunity!

Why do you want to be an emergency doctor?

This is another question that you should expect and be able to crush. You should have a good answer already, but make sure you can respond eloquently because you’ll be asked it a lot. Consider what about your personality and lifestyle make you a good fit for EM and have a good understanding of the drawbacks of the specialty.

What would you want to subspecialize in? (phrased in various more elegant ways)

With most FRCPC-EM programs allowing their residents to combine elective time with time for “developing a subspecialty interest in EM,” this is something you will be asked about. I don’t think you need to know for sure, but you should certainly know what areas interest you. Are you big into research? Education? Toxicology? Hyperbaric medicine? Tropical medicine? Simulation? Public Health? Geriatrics? Sports med? Trauma? Pediatrics? Ultrasound? Quality improvement? Pre-hospital medicine? Cruise ship medicine? Administration? Business? Critical care? Disaster medicine? Palliative care? (I will be writing about the 823023801038 potential EM subspecialty areas some other time!) And, more importantly, why? I think its fair to say that most programs want a resident that will ultimately be able to take on a leadership role in some aspect of our specialty. There’s lots to choose from and no one is going to hold you to it, but I think you should have thought about it.

Tell me about a time when…

These are questions that the interviewers seemed to love when I went through my CaRMS questions. Known as “behavioral-based interviewing,” my understanding is that they’re trying to assess you for a characteristic by asking for a time when you displayed it. You then have to come up with some sort of story to tell them about how you demonstrated leadership or empathy or whatever. In any case, the way to prep for these questions is to come up with a lot of stories from your training that could be applied to demonstrate various traits (if you had a journal at all now would be a great time to bust that out!). I found a guide that goes over prepping for this type of interview question. It’s freely available here starting on page 3. Take a look through it, it’s a good guide for prepping for interviews in general.

3 – Know your programs

I think all of the emergency medicine programs in the country are quite good, but they offer different things. For example, programs can be new or old, small or large, in a big city or a small town, do lots of simulation or little, do ultrasound early or late, have different curricula and do varying amounts of research.

These might be huge positives for some applicants and negatives for others. More likely, some of those characteristics are positives for you and others are negatives. Regardless, you should be able to say why you’d be excited to move to each city and program. If you don’t know anything about them, you’re not going to be able to say.

How should you go about this? The first and easiest way is to check out the websites. We all have them and they should have a lot of good information describing what we’re all about. If you know any medical students or residents from a school they’re also a good resource for this information. Regardless, I think it should be your goal to know enough about each program that you interview at to be able to have a conversation with one of the staff or residents and ask some educated questions about it. We’re proud of our programs and are pumped to talk about them!

4 – Know your flights/accommodations

This is complicated! If you’ve been lucky enough to snag >6 interviews you’re going to be all over the map. This is even worse if you’ve applied to any other specialties and have to fit their interviews in with all of your spare time.

Fortunately, the EM interviews are rationally arranged from East to West or West to East depending on the year. Every program owns one day in the 3 week period that is exclusively theirs for the purpose of EM interviews. Some (most?) programs have a second day, but they generally aren’t allowed to offer interviews to people being interviewed by the program that owns it. This makes it possible for you to attend every single EM interview if you were lucky enough to snag invites to all of them (usually a few people each year pull this off). However, that will hurt. And its also crazy expensive. Save yourself some extra stress en-route (the interviews are enough!) and get this sorted before you start.

Travel tips:

It is really difficult and crazy stressful to get all of your flights/accommodations arranged. Doing this tour in our frigid snowstorm-filled January weather seems to be some sort of perverse Canadian MD right of passage. Occasionally, you’re going to have to take a hit and book a flight/room that’s more expensive than you wanted to. The important thing is to start piece by piece as soon as you can. Most schools get their interview invites in by around Christmas (Toronto being some weird exception – they never seem to send them until sometime well into January), but its hard to make solid plans until you have your interview/tour times. As soon as you do you should be booking.

Making socials is important, especially at the smaller programs, so try to arrange your travel to allow for that. Sometimes the only way for that to happen would be to arrange for teleportation directly between cities. We know that’s not possible and empathize with you, but still think that you being at our social is more important than you catching the end of that other school’s tour. Seriously though, I think the best way to combat this is generally getting a morning tour and an early afternoon interview so that you can be off to the airport as soon as its over.

Money-saving Tips:
-The CFMS used to have a small WestJet discount. I’m not sure if they still do, but every little bit counts!
-Air Canada has had flight passes that have worked well for some in the past. Check out if they would work for your interviews schedule.
-Find a travel buddy – hopefully there’s someone you know with a schedule similar to yours that you can bunk and share taxis with.
-hotwire.com has been popular in previous years for booking cheaper accommodations.
-Bum rides – especially in Ontario, there are lots of people driving from interview to interview. If they’re from Ontario, they’re generally driving. Consider a strategy of holding off on booking buses/trains and offering some cash to the friendly Ontario applicants (yes, this may be more stressful – if you’re OCD about how you’re going to get everywhere definitely figure it out before). They’re generally happy to have the company (and cash) and its much easier and cheaper for you. If it falls through, last minute trains/buses are not hard to book. Hopefully there won’t be a dreaded Ontario snowstorm this year…

As always, thanks for reading. Any and all feedback is appreciated – send me an e-mail or write it in the comments. If you appreciated this post, please follow my RSS feed (top right corner), sign up to receive e-mails when I post (right column), e-mail your friends/colleagues, post it on facebook, tweet it, retweet it or direct others to it!

Brent Thoma @boringem

Flipside: A Dissenting Opinion on RL and NS

As mentioned in my previous posts on Peer-review in FOAM (here and here), following my post on Ringer’s Lactate and Normal Saline I received feedback via e-mail in an e-mail from Dr. Rory Spiegel, an EM resident from Newark, NJ. He offered a well thought out dissenting opinion that I felt deserved a post of its own to counterbalance my previous one.

Here is what he had to say (greetings/goodbyes removed for length):

On the topic of your latest post I have to say I respectfully disagree. I’ve read Dr. Weingart’s posts on this topic as well, and as much respect I have for him, I think on this topic he is mistaken. Well that may be overstating the fact. There may in fact be a small physiological difference but whether that translates into a clinical difference has never been determined. For years now people having been trying to show the superiority of a multitude of fluids over normal saline for countless disease states and as far as I am aware no one has ever done so. Sure when they do preliminary non-randomized trials looking at surrogate endpoints they look better, but whenever you compare them in a random trial it turns out to be equivalent and in some cases, like hydroxyethyl starch, even trend to worse outcomes.

The evidence put forth by Dr. Weingart is not much proof in either direction. There are countless examples of interventions that look great until you do a placebo controlled trial.  In these kind of studies you are never able to account for all the variables. The sicker patients could have needed more blood transfusions which means they were less likely to get LR and more likely to get NS. Even still if you look at the outcomes that actually matter, there was no difference in mortality, ICU length of stay, or need for prolonged RRT.
There is a lack of good evidence overall, otherwise we wouldn’t be having this discussion. I just think it is curious when people who use NS as their preferred fluid of choice get accused of not knowing any better.  I’ve read everything I can find on the topic and I have yet to find any data that shows that LR is superior to NS in any way other than it theoretical reasoning.
In my response I noted some of my motivations for siding with RL. I think RL just makes physiologic sense. This has been backed up with studies which show that, relative to NS, it causes less metabolic derangements in ED patients. Healthy volunteers also seem to like it as they pee earlier and more often and don’t retain as much fluid. Some might also claim that these findings have a viable mechanism to explain them based on kidney physiology and chloride loading in denervated greyhound kidneys…I don’t make that claim, but its interesting to point out a potential mechanism.
Also, I do think that the recent renal findings with lower chloride fluids in ICU patients is relevant, even if it is a surrogate marker, because dialysis sucks for patients and is very expensive for our respective health care systems.
I very much appreciate his note that it should not be assumed that people using NS simply do not know any better. Like Dr. Spiegel, many of them may be very up-to-date on their literature but remain unconvinced of the glories of RL. And they could still be proven right. In his response, he said:
I’ve read both those studies you sent and yes I agree they both found small trends towards the LR in the outcomes they measured. But these are the kind of studies that I initially wrote in protest of. When you look at these surrogate end points there appears to be trends towards benefits, but what we really care about is if LR actually affects patient oriented outcomes. If you go back and look at the early studies on albumin and Hydroxyethyl Starch they looked just like this. As long as you look at surrogate end points they all do better then NS but when you look at the SAFE trial or the large trial recently published in the NEJM these differences don’t translate into mortality or morbidity benefits (and in the later case trends towards increased harm).

Now you could very well argue, why not just use LR for everything since there is no proof that NS is superior and I could not very well disagree with you. The way I look at it is what we do is extremely difficult and we make thousands of decisions each day. So if there is no actual benefit to remembering all the multitudes of fluid choices and the multitudes of situations they may be theoretically beneficial why fill much needed space with seemingly needless stoichiometry.
Now because this is going to be posted and I am feeling quite small when I see the likes of Scott Weingart (one of my EM heroes) posting an assenting opinion I feel it’s only fair I mention that I am not alone in dissenting opinion. The Godfather of emergency medicine, Jerry Hoffman, has proclaimed on countless occasions on EMA that NS is the fluid to give in every situation. If you are in a hypotonic state it is hypertonic in relation. If you are in a hypertonic state it is hypotonic in relation.
Anyway I feel better now that I have someone smarter and far more experienced than myself standing (at least in proxy) on my side of this debate.
Thanks for letting me take part in this discussion. Physiologic reasoning has led us down many blind paths and dark allies. It is only when we use the light of critical research we discover which are dead ends and which lead us and our patients to a better place. It is blogs like yours that will help promote taking such critical looks, so thank you.
Some very good points that deserve consideration. In the end, I am still going to use RL as my go-to fluid for three reasons: 1 – as granted by Dr. Spiegel, there is no evidence that it is better than RL, 2 – I think the “soft”evidence trends in its favor, 3 – it is insignificantly more expensive (see my previous post on the topic – bottom line it’s ~$0.20/L extra).
However, I recognize the wisdom of Dr. Weingart, who made the comment that:

“it just seems like good medicine to treat fluids like any other drug and actually choose the ideal one for the clinical situation.”

And discussed this in depth in his podcast “Choose the Solution Based on the Problem”
In conclusion, having a Coke every once in awhile can be nice! In fact, in many cases it may just be the thing you need to make the perfect drink. Other times it’s going to be Pepsi (D5NS – the same as Coke, only sweeter), Diet Coke (1/2NS) or Diet Pepsi (D51/2NS). There’s certainly a role for all of these fluids. Shoutout to @socmobem and @ETtube for coming up with the rest of the pop equivalents!!

Thanks again to Dr. Spiegel for making me think, supplying the majority of the content of this post and acting as a peer-reviewer for my FOAM. This will most definitely be the last that I write on the topic of fluids for a lonnnng while! Stay tuned for more boring with upcoming posts on otitis media and a follow-up on constipation. I will also continue to expand the mentorship section with a post on preparing for EM residency interviews.

As always, let me know what you think in the comments section below! If you enjoyed this discussion there will be more to come and I’d greatly appreciate it if you followed my RSS feed (see top right corner), signed up for e-mail notifications of new posts (right column), or gave me a RT or follow on twitter!

Brent Thoma @boringem

FOAM: A Market of Ideas

Following my post on the FOAM peer review process (Crowdsourced Instantaneous Feedback) there were some excellent comments made on my blog and twitter.

Thanks especially to Nadim Lalani (ERMentor), Simon Carley (St. Emlyns) and Elisha T (The Chart Review) who commented on my post and inspired this entry.

In particular, Simon Carley noted criticisms of the current peer review process, quoting the BMJ’s Richard Smith who stated that it was “the least worst system we have” and linking to his blog which argued for the superiority of post-publication review. In this highly recommended post, Dr. Smith describes a post-publication review process as: a “market of ideas” which has “many participants and processes and moves like an economic market to determine the value of a paper.”

Previously, I would have wondered what a post-review process would look like. How could journals afford to publish indiscriminately in the hopes that their readers would push the best to the top? And what processes would the readers use to do it?  However, if we take that statement, strike paper and insert blog/podcast/video it would sound just like the FOAM peer review process to me!

The many participants? The entirety of the massive and expanding FOAM community! It is astounding to me to see diverse participants respond in real-time to ideas presented by people on the other side of the planet. I certainly credit my interactions with this community for enhancing my learning and love seeing new ideas presented, considered, discussed and expanded upon.

The many processes? In my initial post, I discussed only the significance that the comments had in serving as peer review, but there is so much more. While negative comments would discredit an idea, even those that do not make a comment can passively demonstrate their negative review by not linking to the post and not retweeting. I suspect that actively ignoring content in this way would do almost as much as a negative comment would as it would barely see the light of day.

Conversely, retweets and links (like those to other resources throughout this article as well as on FOAM updates like the LITFL Reviews) promote the article and act as an endorsement.  Generally, when a subject that has previously been discussed in FOAMlit those making the new post reference the initial content (ie – SMART:EM deserves a huge shout-out for anything related to the PPI in GIB controversy). Other processes that act as a form of positive peer review could include the inclusion of sites with quality content on bloglists, the FOAMEM RSS amalgamation site, and the @FOAMstarter. The Global Medical Education Project has even built this into its design with the ability to rank/promote content.

A Market of Ideas

The huge community of engaged FOAM contributors/readers/listeners/watchers peer-reviews using a market of ideas that accepts a denomination measured in promotional processes such as positive/negative comments, retweets and links.

What other processes promote the atrophy or growth of FOAM contributions?

I am very much enjoying watching this discussion on twitter and look forward to hearing others perspectives. Regardless of how good FOAM peer review may (or may not) be, I think it’s always prudent to take the advice of the SGEM and be skeptical!

Having read this article, I hope that I have convinced you of the importance of giving currency to the ideas you agree with in the FOAM marketplace. Please consider retweeting, forwarding this post, signing up for my RSS feed or my WordPress e-mail list (see right column).

Next Time:

After getting on a bit of an aside with my last two posts on FOAM Peer Review, my next ones will be getting back to the boring old basics. Thank you so much for reading!

Brent Thoma @boringem

Crowdsourced Instantaneous Review: The Peer Review of FOAM?

I was talking to my PD about FOAM the other day and mentioned how crazy it was that we have the ability to produce and disseminate content so widely, easily and cheaply. How great it was that this, in some respects, allowed us to unhinge CME from the clutches of drug and device companies and potentially speed up knowledge translation.

He agreed that it was awesome before adding a “but” of wisdom.

“But it’s not peer-reviewed”

That got me thinking. Much of FOAM critically appraises the literature. Other parts offer small tips and tricks. There’s some mentorship and career advice. Still more provides education and expert commentary. But what would happen if someone said something wrong? If they misread or misinterpreted or missed reading some literature and their inaccurate perspective was adopted by unsuspecting med students and residents (staff are omnipotent, aren’t they?)?

Certainly, this could happen in peer-reviewed literature as well, but there’s at least some semblance of protection from it. Here I can say whatever I want and I don’t have to prove how right I am to anyone before I do.

Batman is real.

See?

I think I got my answer to these questions earlier this week. Shortly after I published my recent post on Normal Saline and Ringer’s Lactate I received an e-mail from Dr. Rory Spiegal, an EM resident from Newark, NJ. He respectfully offered his dissenting opinion. Now, I don’t think I posted anything egregiously incorrect in that post, but everyone is entitled their opinion and, after reviewing the same literature and listening to the same podcasts that I had, he came to a different opinion. That’s going to happen.

However, I am somewhat dismayed that the feedback came to me in the form of a private e-mail. From his perspective, he was being polite. He noted that he didn’t want to “overstep” by posting his opinion in the comments. I can understand his perspective and would probably have done the same had I been in his shoes. Additionally, what resident would want to publicly disagree with the FOAM heroes that I referenced like Scott Weingart and Cliff Reid? I sure wouldn’t.

And that’s unfortunate, because I think reluctance to make a comment neutralizes the substitute that FOAM has for pre-publication peer review: 24/7 near-instantaneous post-publication commentary by anyone in the world with an internet connection. This is a tool that would effectively neutralize the spread of inaccurate information.

I realize that the idea is not novel: Wiki sites offer a way to correct their errors and create content through crowd-sourcing – while incorrect information can get there, it generally does not stay for long. However, I had not thought or read about the lack of pre-publication peer-review in the context of FOAM before now (although I expect comments linking to others that have already discussed this).

In conclusion, I think it is extremely important that these comments need to be fostered. If the people reading my blog do not know that their dissenting opinions will be thoughtfully considered and any errors that I make will be publicly corrected, they might not post them. And I think that we’d all be poorer for that lack of interaction.

As I clearly think it is important for dissenting opinions to be heard, I asked Dr. Spiegal if he might be willing to post the thoughts that he shared in his e-mails. He responded positively, but I didn’t think it would do his well researched and thought-out opinions justice to simply add them into the comments section of a post. And so they will get a post of their own – look for it within the next couple of days.

Now… if I’m wrong about all of this, don’t hold back! Right or wrong, I want to get it straight – so tell me about it!

As always, thanks for reading! If you enjoyed this post I’d be extraordinarily grateful if you followed me on WordPress or twitter, forwarded it on, tweeted it or linked to it.

Brent Thoma @boringem

Normal Saline: The Coke of Crystalloid Fluids

The nurse looked up from my orders with a quizzical expression on her face.

“Why do you always order Ringer’s Lactate?” She asked.

I immediately launched into an intense discussion… errr… one sided conversation… about the merits of various IV solutions and their respective electrolyte values and pH. As her eyes quickly glazed over and she glanced at the clock her expression shifted to one of regret. I sensed that I was losing her and decided to change tactics.

“So basically, Normal Saline is the Coke of crystalloid fluids!” I concluded with a flourish. Then I got the skeptical look. Residents, you know the one – it’s kind of a blank stare with some annoyance mingled in that screams “this guy has no idea what he is talking about!”

And really, can I blame her for that look? For years and years every smart and respected EM physician that has been through the department has been ordering NS for their patients. The nurses didn’t even ask anymore, they just hung it. Why on earth would she believe me, a lowly resident, when I tell her that this fluid was the equivalent of a carbonated beverage acidic enough to corrode metal? Normal saline is the standard – it even says it’s normal in the name!!

And so, I continued to be the loser in my longstanding battle against hypertonic acid that began following my months in the ICU and OR. It was there that some very smart intensivists and anesthesiologists convinced me to consider the error of my NS-loving ways. Upon examination of the literature and the FOAM contributions of legends Dr. Scott Weingart (see his EMCrit podcasts on Chloride Poisoning and Acid-Base) and Dr. Cliff Reid  from RESUS.me, [6/1/12 addendum: Casey Parker of BroomeDocs also weighed in here] I came to the conclusion Normal Saline is as tried, tested and true as a Chevy Vega.

I have no desire to rehash the exceptionally well thought out positions of Drs. Weingart and Reid. If Weingart’s talking about it then it’s too sexy for me anyways!

Therefore, this post has three goals:

-To direct doctors, nurses and residents that I discuss this with to the exceptional FOAM resources on this topic
-To examine just how off-base I was with my desperately provocative statement that NS is the Coke of Crystalloids
-To try to comprehend why it is that we started using NS in the first place and examine why we haven’t changed

With the links to EMCrit and RESUS.me my first goal was accomplished. Please feel free to provide me with any additional reviews of this topic that you think would be helpful.

How Coke-like is Normal Saline? What other options do we have?

The new PV card from ALiEM outlines some of the Crystalloid options quite concisely. As summarized in Dr. Weingart’s post, the composition of each fluid is below. Additional data has been gathered from this article on the pH and SOsm of pop. I calculated the mEq measurement Coke myself using the nutritional information found here. I’d appreciate the help of anyone that is better at chemistry than me to recheck this calculation (I haven’t used molar masses since pre-med!).

mEq pH SOsm Na Cl K Ca Mg Buffer Price (CAN$)
Plasma 7.4 289 142 103 4 5 2 HCO3 – 22-32 N/A
Normal Saline 5.5* 308 154 154 $1.26/L
Ringer’s Lactate 6.5 273 130 109 4 3 Lactate – 28 $1.44/L
Plasmalyte A 6.5 295 140 98 5 3 Gluconate 23/Acetate 27 $7/L
Coca-cola 2.4 493  2.1 #  $1.50/L

*Different references gave me a range of pH values (4.5-7) for NS with the most commonly cited value being 5.5. I have attempted to look into the reason for this without success.
#Chloride content wasn’t provided in the nutritional information. I assume that there would be the same number of moles of Cl as there were of Na, but I’m sure if this is valid so I’ll leave that box blank for now.
$ Cost information is approximate and was provided to my by a pharmacist at my institution several months ago. It may have changed and your institution may get a better/worse deal than us. For my American readers, $1 CAN dollar equates to $1.01 USD 😉

So how NS-like is Coke? From the chart it doesn’t appear to be very similar. It’s much more acidic and its high SOsm is derived from sugar, not sodium chloride. However, after looking at the information about other soft drinks I don’t think it was an unreasonable comparison! NS and Coke are similar in that they are both the most acidic and hypertonic solutions in their respective classes (excluding weird soft drinks like Schweppes Bitter Lemon that I don’t even think exist in North America).

Where did Normal Saline come from, anyways?

Put another way, how is it that Hypertonic Acid became our most prolific IV fluid? I was delighted to find a paper that answered this question. See here for a 2008 review by Awad, Allison and Lobo of the history of Normal Saline.

To paraphrase, NS basically came out of nowhere. The first time hypovolemia was recognized as a contributor to morbidity and mortality came with the cholera epidemics of the 1800’s and a few bright physicians began experimenting with fluid resuscitation with various hypotonic solutions described in the language of the apothecary’s of the time. One of the earliest solutions was created by a Dr. Latta:

Latta T. (1832). Saline venous injections in cases of malignant cholera performed while in the vapour-bath. Part i. Lancet, 19, 173-176.

Unfortunately, I’d need a museum to find the original reference. Apparently, it included Na 134, Cl 118 and HCO3- 16, making it a substantially more physiologic solution than “Normal” Saline! Unfortunately, Dr. Latta died of tuberculosis the next year and fluid resuscitation was crushed by its critics.

The story after that gets involved and speculative. Widespread use of NS seems to have started sometime in the early 20th century with multiple physicians issuing warnings about the dangers of such a concentrated salt solution that were quickly forgotten. Regardless, how this solution came into widespread use seems to defy common sense as it has been demonstrated to be detrimental and would certainly not be our “ideal solution” if we were to come up with one today.

What would be the ideal resuscitation fluid?

Check out what Dr. Weingart thinks.

Why don’t we change?

At the end of the day, I think there are a few reasons why we haven’t embraced a more physiologic IV fluid in emergency medicine. Based on the options listed above, Plasmalyte A and Ringer’s Lactate may be viable alternatives.

However, Plasmalyte gets a huge knock for being expensive. While $5 extra might not seem like a lot, with the volume of fluid that gets used in the ED it is likely prohibitive (interestingly, that hasn’t stopped the OR at my institution from using quite a bit of it intra-operatively). As for RL, I’d gladly chip in an extra $0.18 for the good stuff if I ever end up in your ED.

What are some barriers to the widespread use of Ringer’s Lactate in the ED?

Concerns with Transfusion
As it contains Calcium, there are worries that it could cause blood to clot if they are given together.  Transfusing RBC’s with it is considered contraindicated where I work, but as this study and this study and this study attest, that is likely a myth, especially when the blood is being transfused quickly. However, I’m not well-versed or experienced enough to comment on this research and Canadian Blood Services states bluntly that you should never put them in the same line together. A quick google search led me to a California Blood Bank Society who gave the practice a big thumbs down after acknowledging that people do it anyway.

Based on this, I wouldn’t run blood with it or recommend that anyone do so. However, I don’t think this is a good reason not to use it in all of the patients that are not being transfused. Changing a line doesn’t take that long.

Concerns with Drug Compatibility
When I have asked nursing staff about their concerns with RL they have noted that many commonly used ED medications are considered incompatible with it. In particular, midazolam, dilantin and tazocin are commonly used ED drugs that are apparently incompatible.

While a few incompatibilities certainly shouldn’t relegate RL to the dustbin of ED history, I’d love to hear a pharmacist’s perspective on the reasons for the contraindications and the potential complications that would result if they were not observed.

Concerns that it will cause a Lactic Acidosis
Some believe that it will cause a lactic acidosis in their patient. I went reading far and wide trying to understand the biochemistry behind this. If I am incorrect or this can be better clarified, please make a comment or send a message.

If this description is hard to follow, consider heading over to one of my presentations on Prezi and checking out a presentation I did on this topic there. The part specifically dealing with the lactic acidosis issue is on Slide #32

So far as I can tell, this is a myth that makes no sense. Yes, lactate is in RL (it has a much more honest name than NS!). However, this lactate is not being transported out of a cell with an associated H+ molecule. Therefore, it would not cause an acidosis. [6/1/12 addendum – this is explained much more elegantly in this article].

Could it falsely elevate your lactate reading on your labs? How about in a liver failure patient? Perhaps, but there is such a very small amount of Lactate in RL relative to the body’s fluid volume that I feel it would be unlikely [6/1/12 – but alas, I am wrong. 28mEq Lactate = 28mmol/3.5L plasma volume = 8mmol/L change if no lactate is cleared. It would still not be associated with an acidosis though!]. More important than lab readings, your patient would likely do better with this fluid as it is more physiologic, does not cause a NAGMA, and kidneys like it more (see previous references to RESUS.me and EMCrit).

Conclusion

In conclusion, next time you’re ordering fluids for a patient in the ED consider: should they get IV Coca-cola? Or something healthier??

Once again, thanks so much to everyone for reading. If you liked what you saw, I’d be honored if you commented (I’ve learned a ton from my comments so far!), followed my blog (RSS feed and e-mails are available), followed me on twitter @boringem and/or tweeted/forwarded it on to others. Thanks!

Brent Thoma @boringem