Downloaded from http://emj.bmj.com/ on June 18, 2015 - Published by group.bmj.com
PostScript
LETTERS
CanFOAMed: Canadians can do FOAM too Dear Editor We read with interest the article by Grundlingh, Harris and Carley on #FOAM in the October issue of EMJ.1 The authors did a good job covering the subject and providing a list of FOAMed resources. Social media is turning medical education on its head. The top down, 20th century, didactic method of knowledge translation is being replaced by online resources that are timely, articulate, interactive and widely distributed. The historical one-way flow of information has given way to a form of education where content producers and learners are able to interact to enhance understanding and speed knowledge translation. As FOAMed has become a worldwide phenomenon, we were disappointed by the absence of Canadian content in the article. In addition to making contributions to major sites such as Life in the Fast Lane (LITFL—Australia—http://lifeinthefastlane. com), Academic Life in EM (ALiEM—the USA—http://academiclifeinem.com) and Prehospital and Retrieval Medicine (PHARM—Australia—http:// prehospitalmed.com), Canadians are contributing with FOAM resources such as: ▸ The Skeptic’s Guide to Emergency Medicine (http://thesgem.com) ▸ The Chart Review (http://thechartreview. org) ▸ Boring EM (http://boringem.org) ▸ SOCMOB (http://socmob.org) ▸ Flipped EM Classroom (http:// flippedclassroom.wordpress.com) ▸ Manu et Corde (http://manuetcorde.org) The LITFL releases a weekly review of the best FOAM from around the world that is highly recommended to any readers looking to keep up-to-date on this growing body of learning resources.2 In addition, one of us has recently contributed to an international team of writers to raise awareness around FOAM consumption and uptake by readers and delves deeper into issues with the philosophies and epistemologies of FOAM information.3 4 We hope your audience will find these CanFOAMed resources interesting and useful (see online supplementary appendix). Viva la FOAM. Sincerely, Ken Milne (@TheSGEM)
Emerg Med J April 2014 Vol 31 No 4
Brent Thoma (@BoringEM) Chris Bond (@socmobem) Eve Purdy (@Purdy_eve) Stella Yiu (@Stella_Yiu) Elisha Targonsky (@ETTube) Teresa Chan (@TChanMD) Ken Milne,1 Brent Thoma,2 Chris Bond,3 Eve Purdy,4 Stella Yiu,5 Elisha Targonsky,6 Teresa Chan7 1
Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada 2 Emergency Medicine Residency Program, University of Saskatchewan, Saskatoon, Saskatchewan, Canada 3 Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada 4 Department of Undergraduate Medicine, Queen’s University, Kingston, Ontario, Canada 5 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada 6 Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada 7 Clinical Scholar, Division of Emergency Medicine, Department of Medicine, McMaster University, McMaster Clinic, Hamilton General Hospital, Hamilton, Ontario, Canada Correspondence to Dr Teresa Chan, Clinical Scholar, Division of Emergency Medicine, Department of Medicine, McMaster University, Rm 254, McMaster Clinic, Hamilton General Hospital, Hamilton, Ontario, Canada L8L 2X2; [email protected], [email protected] Contributors WKM conceived the letter and recruited us as coauthors. WKM, BT, CB, EP, SY, ET and TC all participated in the authorship of the letter collaboratively and also actively participated in editing the document for content, clarity and brevity. TC finalised the formatting and submitted the manuscript. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10. 1136/emermed-2013-203341) To cite Milne K, Thoma B, Bond C, et al. Emerg Med J 2014;31:351. Accepted 10 November 2013 Published Online First 10 December 2013 Emerg Med J 2014;31:351. doi:10.1136/emermed-2013-203341
REFERENCES 1
2
3
4
Grundlingh J, Harris T, Carley S. FOAM: the Internet, social media and medical education. Special data supplement. Emerg Med J 2013;30. Retrieved online 14 October 2013. http://emj.bmj.com/content/30/10/ suppl/DC1 Cadogan M, Nickson C, eds. Life in the Fast Lane Blog. 2013. Retrieved 14 October 2013. http:// lifeinthefastlane.com Hayes B, Chan T, Lin M. Is FOAM to Blame when a medical error occurs? 2013. Published 17 September 2013. Retrieved 14 October 2013. http:// academiclifeinem.com/ is-foam-to-blame-when-a-medical-error-occurs/ Lin M, Chan T, Hayes B. 5 Rules To Guide Your Approach to Learning in Social Media. 2013. Published 18 September 2013. Retrieved 14 October
2013. http://academiclifeinem.com/5-rules-to-guideyour-approach-to-learning-in-social-media/
So, doctor, was I worth £10? Dear Editor I write this letter in response to the recent survey which showed a third of general practitioners to support patient fees for ‘unnecessary’ Accident & Emergency (A&E) visits.1 The idea is that patients would be charged £5–£10 and this is refunded if doctors deemed the visit appropriate. I propose three key reasons why this charge would be impractical, unethical and dangerous. First, A&E doctors would have to get into discussions with patients as to why their payment cannot be refunded. These discussions will be awkward for the doctors, impact upon the doctor–patient relationship and also take up the doctors’ time, where resources are what we are trying to save in the first place. Second, it stops the NHS being ‘free at the point of care’ which is a fundamental feature of its constitution. This may defer certain lower-economic patient groups (those groups that may have less education about heath and illness in the first place) from presenting to A&E when something may actually be wrong. Third, when patients present to A&E, they do not wait in a busy waiting room for fun! They believe that something needs urgent medical attention. This intervention would not educate patients as it is unlikely that doctors would have time to fully explain why a patient’s visit was justified or not. There would be discrepancy between different doctors in what they believe to be a ‘legitimate visit’ with some willing to refund for certain presentations that others believe to be ‘not warranting a visit’. This would confuse patients further and not help them to make ‘better decisions’ the next time. To conclude, although vast costs are incurred by patients who attend A&E without requiring urgent treatment,2 charging patients is not the answer. Patients who are without extensive medical knowledge are not trained to know when symptoms signify something sinister. However, perhaps further educational intervention that teaches the public more about the different options available to them would help direct them to the right place.
351
Downloaded from http://emj.bmj.com/ on June 18, 2015 - Published by group.bmj.com
PostScript Lauren Waterman Correspondence to Dr Lauren Waterman, Royal Sussex County Hospital, Eastern Road, Brighton BN25BE, USA; [email protected], [email protected] Contributors This article was written by LW. There were no other authors or contributors to this article. Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
To cite Waterman L. Emerg Med J 2014;31:351–352. Accepted 8 February 2014 Published Online First 3 March 2014
2
Emerg Med J 2014;31:351–352. doi:10.1136/emermed-2014-203611
Third of GPs back charging £10 to keep timewasters away from A&E units. http://www.independent.co.uk/ life-style/health-and-families/health-news/charge-10-tokeep-timewasters-away-from-ae-units-say-gps9035741.html A&E timewasters cost NHS £27m. http://www. express.co.uk/news/uk/208944/A-E-time-wasters-costNHS-27m
IMAGES IN EMERGENCY MEDICINE
Finger injury A male in his 20s put on his work gloves and felt something inside the right fourth digit, without any pain or discernible ‘bite.’ He shook the gloves out and squashed the offending agent (figure 1). He continued to work and upon removing his gloves 2 h later, noticed discolouration on the right fourth digit. He then presented to the emergency department for evaluation. On exam, his fourth finger looked contused, with dark purple-brown discolouration (figure 2). There was no tenderness, swelling or bite marks. He had normal capillary refill and his finger had full range of motion. There were no other injuries and the patient was otherwise asymptomatic. He did not try any treatments at home. Diagnosis: skin discolouration due to millipede exposure. Millipedes are elongated multisegemental arthropods in the class Diplopoda that are vegetarian scavengers and do not bite. However, they have a defence mechanism which involves
Figure 2
Patient’s finger.
secretion of chemicals including quinones, hydrogen cyanide and aldehydes.1 2 When a millipede feels threatened, it emits these compounds from pores along its segments. Upon skin contact, they cause discolouration from dark yellow to purple– mahogany.3 Treatment is supportive with copious washing of area with soap and water. The application of steroid cream is indicated by pain, swelling or pruritus. Opthalmological consultation may be required in the case of eye exposures, which can result in conjunctivitis, keratitis and periorbital oedema.4 Therapy includes copious ocular irrigation and topical corticosteroids. The skin lesions usually fade away, except in the case of ocular giant millipede exposures, where residual periorbital skin depigmentation may persist. Saleen Manternach, Patil Armenian Department of Emergency Medicine, UCSF-Fresno, Fresno, California, USA Correspondence to Dr Saleen Manternach, Department of Emergency Medicine, UCSF Fresno Medical Education Program, 155 N. Fresno Street, Suite 206, Fresno, CA 93701, USA; [email protected] Contributors Both SM and PA contributed to this manuscript. Both authors contributed to the conception and design and interpretation of the case. Both authors drafted and revised the text and both approve the final work to be published. SM is responsible for the overall content as guarantor. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. To cite Manternach S, Armenian P. Emerg Med J 2014;31:352. Accepted 8 August 2013 Emerg Med J 2014;31:352. doi:10.1136/emermed-2013-203085
REFERENCES 1 2 3
Figure 1 Offending agent. 352
4
Dar NR, Raza N, Rehman SB. Millipede burn at an unusual site mimicking child abuse in an 8-year-old girl. Clin Pediatr (Phila) 2008;47:490–2. Hendrickson R. Millipede Exposure. Clin Toxicol (Phila) 2005;43:211–12. Shpall S, Frieden I. Mahogany discoloration of the skin due to the defensive secretion of a millipede. Pediatr Dermatol 1991;8:25–7. Hudson BJ, Parsons GA. Giant millipede ‘burns’ and the eye. Trans RSTMH 1997;91:183–2.
Emerg Med J April 2014 Vol 31 No 4
Downloaded from http://emj.bmj.com/ on June 18, 2015 - Published by group.bmj.com
So, doctor, was I worth £10? Lauren Waterman Emerg Med J 2014 31: 351-352 originally published online March 3, 2014
doi: 10.1136/emermed-2014-203611 Updated information and services can be found at: http://emj.bmj.com/content/31/4/351.2
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript
LETTERS
CanFOAMed: Canadians can do FOAM too Dear Editor We read with interest the article by Grundlingh, Harris and Carley on #FOAM in the October issue of EMJ.1 The authors did a good job covering the subject and providing a list of FOAMed resources. Social media is turning medical education on its head. The top down, 20th century, didactic method of knowledge translation is being replaced by online resources that are timely, articulate, interactive and widely distributed. The historical one-way flow of information has given way to a form of education where content producers and learners are able to interact to enhance understanding and speed knowledge translation. As FOAMed has become a worldwide phenomenon, we were disappointed by the absence of Canadian content in the article. In addition to making contributions to major sites such as Life in the Fast Lane (LITFL—Australia—http://lifeinthefastlane. com), Academic Life in EM (ALiEM—the USA—http://academiclifeinem.com) and Prehospital and Retrieval Medicine (PHARM—Australia—http:// prehospitalmed.com), Canadians are contributing with FOAM resources such as: ▸ The Skeptic’s Guide to Emergency Medicine (http://thesgem.com) ▸ The Chart Review (http://thechartreview. org) ▸ Boring EM (http://boringem.org) ▸ SOCMOB (http://socmob.org) ▸ Flipped EM Classroom (http:// flippedclassroom.wordpress.com) ▸ Manu et Corde (http://manuetcorde.org) The LITFL releases a weekly review of the best FOAM from around the world that is highly recommended to any readers looking to keep up-to-date on this growing body of learning resources.2 In addition, one of us has recently contributed to an international team of writers to raise awareness around FOAM consumption and uptake by readers and delves deeper into issues with the philosophies and epistemologies of FOAM information.3 4 We hope your audience will find these CanFOAMed resources interesting and useful (see online supplementary appendix). Viva la FOAM. Sincerely, Ken Milne (@TheSGEM)
Emerg Med J April 2014 Vol 31 No 4
Brent Thoma (@BoringEM) Chris Bond (@socmobem) Eve Purdy (@Purdy_eve) Stella Yiu (@Stella_Yiu) Elisha Targonsky (@ETTube) Teresa Chan (@TChanMD) Ken Milne,1 Brent Thoma,2 Chris Bond,3 Eve Purdy,4 Stella Yiu,5 Elisha Targonsky,6 Teresa Chan7 1
Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada 2 Emergency Medicine Residency Program, University of Saskatchewan, Saskatoon, Saskatchewan, Canada 3 Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada 4 Department of Undergraduate Medicine, Queen’s University, Kingston, Ontario, Canada 5 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada 6 Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada 7 Clinical Scholar, Division of Emergency Medicine, Department of Medicine, McMaster University, McMaster Clinic, Hamilton General Hospital, Hamilton, Ontario, Canada Correspondence to Dr Teresa Chan, Clinical Scholar, Division of Emergency Medicine, Department of Medicine, McMaster University, Rm 254, McMaster Clinic, Hamilton General Hospital, Hamilton, Ontario, Canada L8L 2X2; [email protected], [email protected] Contributors WKM conceived the letter and recruited us as coauthors. WKM, BT, CB, EP, SY, ET and TC all participated in the authorship of the letter collaboratively and also actively participated in editing the document for content, clarity and brevity. TC finalised the formatting and submitted the manuscript. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10. 1136/emermed-2013-203341) To cite Milne K, Thoma B, Bond C, et al. Emerg Med J 2014;31:351. Accepted 10 November 2013 Published Online First 10 December 2013 Emerg Med J 2014;31:351. doi:10.1136/emermed-2013-203341
REFERENCES 1
2
3
4
Grundlingh J, Harris T, Carley S. FOAM: the Internet, social media and medical education. Special data supplement. Emerg Med J 2013;30. Retrieved online 14 October 2013. http://emj.bmj.com/content/30/10/ suppl/DC1 Cadogan M, Nickson C, eds. Life in the Fast Lane Blog. 2013. Retrieved 14 October 2013. http:// lifeinthefastlane.com Hayes B, Chan T, Lin M. Is FOAM to Blame when a medical error occurs? 2013. Published 17 September 2013. Retrieved 14 October 2013. http:// academiclifeinem.com/ is-foam-to-blame-when-a-medical-error-occurs/ Lin M, Chan T, Hayes B. 5 Rules To Guide Your Approach to Learning in Social Media. 2013. Published 18 September 2013. Retrieved 14 October
2013. http://academiclifeinem.com/5-rules-to-guideyour-approach-to-learning-in-social-media/
So, doctor, was I worth £10? Dear Editor I write this letter in response to the recent survey which showed a third of general practitioners to support patient fees for ‘unnecessary’ Accident & Emergency (A&E) visits.1 The idea is that patients would be charged £5–£10 and this is refunded if doctors deemed the visit appropriate. I propose three key reasons why this charge would be impractical, unethical and dangerous. First, A&E doctors would have to get into discussions with patients as to why their payment cannot be refunded. These discussions will be awkward for the doctors, impact upon the doctor–patient relationship and also take up the doctors’ time, where resources are what we are trying to save in the first place. Second, it stops the NHS being ‘free at the point of care’ which is a fundamental feature of its constitution. This may defer certain lower-economic patient groups (those groups that may have less education about heath and illness in the first place) from presenting to A&E when something may actually be wrong. Third, when patients present to A&E, they do not wait in a busy waiting room for fun! They believe that something needs urgent medical attention. This intervention would not educate patients as it is unlikely that doctors would have time to fully explain why a patient’s visit was justified or not. There would be discrepancy between different doctors in what they believe to be a ‘legitimate visit’ with some willing to refund for certain presentations that others believe to be ‘not warranting a visit’. This would confuse patients further and not help them to make ‘better decisions’ the next time. To conclude, although vast costs are incurred by patients who attend A&E without requiring urgent treatment,2 charging patients is not the answer. Patients who are without extensive medical knowledge are not trained to know when symptoms signify something sinister. However, perhaps further educational intervention that teaches the public more about the different options available to them would help direct them to the right place.
351
Downloaded from http://emj.bmj.com/ on June 18, 2015 - Published by group.bmj.com
PostScript Lauren Waterman Correspondence to Dr Lauren Waterman, Royal Sussex County Hospital, Eastern Road, Brighton BN25BE, USA; [email protected], [email protected] Contributors This article was written by LW. There were no other authors or contributors to this article. Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
To cite Waterman L. Emerg Med J 2014;31:351–352. Accepted 8 February 2014 Published Online First 3 March 2014
2
Emerg Med J 2014;31:351–352. doi:10.1136/emermed-2014-203611
Third of GPs back charging £10 to keep timewasters away from A&E units. http://www.independent.co.uk/ life-style/health-and-families/health-news/charge-10-tokeep-timewasters-away-from-ae-units-say-gps9035741.html A&E timewasters cost NHS £27m. http://www. express.co.uk/news/uk/208944/A-E-time-wasters-costNHS-27m
IMAGES IN EMERGENCY MEDICINE
Finger injury A male in his 20s put on his work gloves and felt something inside the right fourth digit, without any pain or discernible ‘bite.’ He shook the gloves out and squashed the offending agent (figure 1). He continued to work and upon removing his gloves 2 h later, noticed discolouration on the right fourth digit. He then presented to the emergency department for evaluation. On exam, his fourth finger looked contused, with dark purple-brown discolouration (figure 2). There was no tenderness, swelling or bite marks. He had normal capillary refill and his finger had full range of motion. There were no other injuries and the patient was otherwise asymptomatic. He did not try any treatments at home. Diagnosis: skin discolouration due to millipede exposure. Millipedes are elongated multisegemental arthropods in the class Diplopoda that are vegetarian scavengers and do not bite. However, they have a defence mechanism which involves
Figure 2
Patient’s finger.
secretion of chemicals including quinones, hydrogen cyanide and aldehydes.1 2 When a millipede feels threatened, it emits these compounds from pores along its segments. Upon skin contact, they cause discolouration from dark yellow to purple– mahogany.3 Treatment is supportive with copious washing of area with soap and water. The application of steroid cream is indicated by pain, swelling or pruritus. Opthalmological consultation may be required in the case of eye exposures, which can result in conjunctivitis, keratitis and periorbital oedema.4 Therapy includes copious ocular irrigation and topical corticosteroids. The skin lesions usually fade away, except in the case of ocular giant millipede exposures, where residual periorbital skin depigmentation may persist. Saleen Manternach, Patil Armenian Department of Emergency Medicine, UCSF-Fresno, Fresno, California, USA Correspondence to Dr Saleen Manternach, Department of Emergency Medicine, UCSF Fresno Medical Education Program, 155 N. Fresno Street, Suite 206, Fresno, CA 93701, USA; [email protected] Contributors Both SM and PA contributed to this manuscript. Both authors contributed to the conception and design and interpretation of the case. Both authors drafted and revised the text and both approve the final work to be published. SM is responsible for the overall content as guarantor. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. To cite Manternach S, Armenian P. Emerg Med J 2014;31:352. Accepted 8 August 2013 Emerg Med J 2014;31:352. doi:10.1136/emermed-2013-203085
REFERENCES 1 2 3
Figure 1 Offending agent. 352
4
Dar NR, Raza N, Rehman SB. Millipede burn at an unusual site mimicking child abuse in an 8-year-old girl. Clin Pediatr (Phila) 2008;47:490–2. Hendrickson R. Millipede Exposure. Clin Toxicol (Phila) 2005;43:211–12. Shpall S, Frieden I. Mahogany discoloration of the skin due to the defensive secretion of a millipede. Pediatr Dermatol 1991;8:25–7. Hudson BJ, Parsons GA. Giant millipede ‘burns’ and the eye. Trans RSTMH 1997;91:183–2.
Emerg Med J April 2014 Vol 31 No 4
Downloaded from http://emj.bmj.com/ on June 18, 2015 - Published by group.bmj.com
So, doctor, was I worth £10? Lauren Waterman Emerg Med J 2014 31: 351-352 originally published online March 3, 2014
doi: 10.1136/emermed-2014-203611 Updated information and services can be found at: http://emj.bmj.com/content/31/4/351.2
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
