Category Archives: Random

Scooped yet again! Teaching Point on a Non-Traditional IO Application

One of my senior residents, now graduated and a fancy informatics fellow and general badass at Stanford, Christian Rose and I used to discuss how we wondered if in extenuating circumstances one could use an intraosseous drill / needle to trephine a skull and drain a rapidly-expanding intraaxial hematoma in a crashing patients. Like most emergency medicine doctors, I find life-saving procedures interesting and cool and even though I would never want the lifestyle that accompanies neurosurgery, being able to do these interventions in a resource-limited setting is something I aspire to if it had to be done. (I’ve seen a burr hole and clot evacuation done once by an ED physician who had been trained in the military and done them abroad in forward operating theaters — he borrowed a drill from the ortho OR. It was successful, appeared fairly easy, and saved a life.)

This was all just theoretical until I read this post from the EMCore conference blog by Peter Kas. He relates a story recently published as a case report in Injury of using an EZ-IO drill and a 25 mm 15 ga intraosseous needle to drain a rapidly-expanding epidural hematoma in a pedestrian who was struck by an auto who presented and had a rapid decline in GCS and clinical signs of herniation. This procedure took about 8 minutes — shaving and sterilizing the scalp, and was done in the anesthesiology prep area while the neurosurgeons prepped for a craniotomy. They were able to aspirate ~ 30 mL of blood, with resulting improvement in the pupillary exam. A formal craniotomy was completed, and the patient had a good outcome. 

The authors note that this is unlikely to provide definitive management, given that most significant hematoma requiring craniotomy are of a more solid consistency that would be difficult to drain entirely via this route, but that it might be utilized by ED providers needing to transfer a patient over a long distance to definitive care. They specifically describe how they envision the procedure:

We propose the site of insertion should be the point of maximal clot depth and therefore localisation of the insertion point would be on a case by case basis. Most extradural haematomas requiring emergency craniotomy are of sufficient size that we postulate that failure to place the needle into the haematoma is unlikely but a potential complication.

Anyway, fun fact of the day, and perhaps someday (hopefully this will never come up) a last-ditch hail mary move that is a little easier and possibly safer/faster than borrowing a drill from your local orthopod and hoping you don’t go too deep.


Bulstrode H1, Kabwama S2, Durnford A3, Hempenstall J4, Chakraborty A5. Temporising extradural haematoma by craniostomy using an intraosseous needle. Injury. 2017 May;48(5):1098-1100. PMID: 28238447. [PubMed] [Read by QxMD]

Outcomes of medical emergencies on commercial airline flights.

As I get warmed up to this whole attempting-to-post-regularly thing, I’m going to share some articles that I came across during medical school that I found interesting or amusing, along with the more serious stuff that utilizes a little bit more critical thinking– first up is this review article on outcomes of medical emergencies on commercial airline flights, from some emergency physicians at U. Pittsburgh and ECU. The authors reviewed records of in-flight medical emergency calls from five domestic and international airlines to a physician-directed medical communications center over an approximately a two year period and reported the epidemiology of in-flight emergencies, along with some outcomes and some commentary.

The most common chief complaints were syncopal events and GI distress, which is not surprising. There were, scattered amongst the less serious complaints, 38 cardiac arrests and 36 deaths reported, alongside some OB/GYN emergencies (most of which were less than 24 weeks and labeled as possible abortions/vaginal bleeding, with 18% involving labor beyond 24 weeks). Physicians provided the majority of assistance, with nurses and EMTs stepping up to the plate as well. The article also describes the FAA laws on medical control, liability issues pertaining to providing care on-board a flight (the 1998 Aviation Medical Assistance Act includes a Good Sa- maritan provision protecting passengers who offer medical assistance from liability, other than liability for gross negligence or willful misconduct), and offers some approaches to common problems. Also, interestingly, a supplementary appendix contains a list of items found in the “Enhanced Emergency Kit” carried by many airlines, which has a lot more than one might expect to find on an airplane. I am planning on working on an educational project for medical students on EM clerkships involving this list– could be fun.

What this study doesn’t address is something I read somewhere a long time ago about a resuscitation that took place on a plane following an arrest. Two physicians on-board initiated CPR and performed chest compressions for 40 minutes or so and applied an AED, which did not find a shockable rhythm. When they told the flight attendants that they were going to pronounce the patient and terminate resuscitative efforts, they were told that the flight attendants were required by policy to continue CPR until they had arrived back at an airport– I can’t remember the exact details, but I believe they decided that they would keep working on the patient, if only to spare the flight attendants the experience. The anecdote, apocryphal as it may be, raises an interesting question though– who can terminate resuscitative efforts on-board an airplane? The captain? On-line medical control? Any random on-board physician or nurse? I’m not really sure what I would do in such a position, but hopefully (and the data seems to suggest that) it will never come up,


Peterson DC1, Martin-Gill C, Guyette FX, Tobias AZ, McCarthy CE, Harrington ST, Delbridge TR, Yealy DM. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013 May 30;368(22):2075-83. PMID: 23718164. [PubMed] [Read by QxMD]

Endings & Beginnings

A little over a week ago, I was one of thousands of medical students across the United States who participated in the NRMP’s Match process, wherein 4th year medical students find out where they will be heading to train in the specialty of their choosing. In my case, the specialty is Emergency Medicine, and where I’m headed is San Francisco, CA– I was humbled and ecstatic to have matched to UCSF, which after a lot of deliberation ended up being my first choice. Before the Match happened, I interviewed at sixteen programs across the country and genuinely loved things about all of them– I would have been lucky to end up at any of the programs I interviewed at, and am confident that I would have come out of any of them clinically well-prepared. That said, UCSF as a fairly young emergency medicine program at such a well-established research center, in a city like San Francisco, stood out as a place that would be particularly great to spend the next several years learning to rule out the proverbial badness while also beginning the next chapter of my life with my partner Karen and our black labrador Hal. Suffice to say, I’m excited for this next part of my life– I have one rotation left in medical school (radiology), a wedding, and a cross-country relocation to get through, but I’m sure that it will be here before I know it.

As part of my preparation for residency, I am going to attempt something I’ve done a few times before and been historically not-so-great at: journaling. Only now, I feel like I have a specific thing to write about, and a rationale– and the internet makes this much easier. I plan on using this website as sort of a journal club for myself, inspired by one of my former faculty members, Dr. Ryan Radecki who runs his own very well-written and informative blog EM Literature of Note. I hope that it will be useful to myself, as a place to collate my thoughts and to practice critical appraisal of the literature, and that someday it might even be useful to others or allow me to participate more fully in the #FOAMed movement– I have so far been more of a lurker, as my medical student status made me feel reluctant to contribute, and I look forward to trying to add some content.

For my first post, I’ll share something I found amusing and relevant to the interview season– an article from our neighbors in the frozen tundra region (I think?) of Toronto: Rainy Weather and Medical School Interviews, by Drs. Redelmeier and Baxter, of the University of Toronto. They looked at interviewer ratings of just under 3,000 applicants who participated in consecutive medical school interviews  between 2004 and 2009 and examined the relationship of weather to admission committee members’ perceptions of applicants.

What they found is perhaps not surprising, though I think if you asked most people if the weather on a day you interview “mattered” they would have a difficult time quantifying exactly how much– according to these authors, interviewing on a rainy day (operationalized a priori if  government records reflected precipitation– including freezing rain, snow and hail– occurred in the morning or afternoon) conferred a disadvantage equal to a 10% lower score on the MCAT, or Medical College Admissions Test. The disadvantage was translated from a score disparity that was statistically significant (barely, but still!). The authors remark in the conclusion that “magnitude of the specific influence may be modest, but such small differences can be important in some cases because each year there are about 100 candidates who receive a score within 1% of the admission threshold”, and end by reminding us of something important about cognitive biases that we (especially in EM) would do well to remember regarding all biases: “Calling attention to these issues may diminish their impact on judgment.” (For better or for worse, I mentioned this article during an interview or two when the weather was terrible– luckily, it was a sunny day in San Francisco.)

Anyway, I hope to do a lot of reading and writing about cognitive biases and decision-making in this blog, and how we in the ED can use knowledge of biases and common cognitive stumbling blocks to improve our own practice. I hope that I manage to keep up this endeavor, and I hope that eventually it can be of use to others. If you got this far, thanks, and keep checking in– I promise I’ll work on the brevity part of blogging. 🙂