Why we should be very wary of using clot busting drugs in CVA

Why we should be very wary of using clot busting drugs in CVA.

A concise treatise on the problems with TPa. Well Done!

Defikopter drone air-drops a defibrillator to EMTs on the ground

The Defikopter is a UAV that can be activated by a smartphone app to automatically take to the skies and drop a defibrillator to medical personnel on the ground, shaving precious seconds from the time it takes to receive treatment for cardiac arrest.

The idea for the drone comes from Definetz, a non-profit group dedicated to preventing deaths due to heart failure.

via Defikopter drone air-drops a defibrillator to EMTs on the ground.

Interesting idea. Won’t work here in the Land o’ the Lawsuit.

Budweiser is most popular beer among injured ER patients, pilot study says – NBC News.com

There’s a weird risk factor. What’s AB putting in their beers?*

Though Budweiser has 9.1 percent of the national beer market, it represented 15 percent of the of the E.R. “market.” The disparity was even more pronounced for Steel Reserve. It has only .8 percent of the market nationally, but accounted for 14.7 percent of the E.R. market. In all, Steel Reserve, Colt 45, Bud Ice, and another malt liquor, King Cobra, account for only 2.4 percent of the U.S. beer market, but accounted for 46 percent of the beer consumed by E.R. patients.

via Budweiser is most popular beer among injured ER patients, pilot study says – NBC News.com.

*Clearly a joke, don’t sue.

I met several CPR survivors today; I was involved with some of them

At the Fort Worth Municipal building, a gathering of AED/CPR survivors. I was told 10 of them; they came with their families, and there were a lot of lay rescuers and EMS, who as usual deserve the credit for a ‘save’, as if they don’t get the heart restarted in the field there’s not a lot we can do in the ER.

I was also told I was involved in the care of 4 of them. Crazy odds.

Two patients knew of me (probably from billing, frankly, none were awake in the ED), and they were 100% neurologically intact. We had nice chats, and I got my photo with both, but as I didn’t ask their permission to post them, I won’t.

Still, wow.

It’s incredibly humbling to have follow-up on a happy ED case, and when it’s neurologically intact CPR survivors, it’s the equivalent of a Moon shot for an ER guy, and today I got four. Four.

(It’s an occupational hazard in the ED that we meet/greet/diagnose/stabilize and disposition, and what that individual patients’ medical future holds we have no idea unless we go out of our way, and we’re busy enough nobody I know goes out of their way to follow up cases).

I am renewed. I’m not a Pollyanna doc (read the blog), but this has my attention: the practice has changed, and it works.


Our unrealistic attitudes about death, through a doctor’s eyes

We all die. Here’s just a snippet from this doctors’ experience:

…Sometimes an estranged family member is “flying in next week to get all this straightened out.” This is usually the person who knows the least about her struggling parent’s health; she’ll have problems bringing her white horse as carry-on luggage. This person may think she is being driven by compassion, but a good deal of what got her on the plane was the guilt and regret of living far away and having not done any of the heavy lifting in caring for her parent.

via Washington Post.

I’ve seen this many, many times in my ED; the child of the nearly-deceased who has been doing all the caring comes in, says essentially ‘let them die comfortably’, then come in the ones who haven’t been doing the work, haven’t seen the daily decline, and they browbeat the first into a retreat. ‘I think I misunderstood, we need to do everything’ they say to me while watching the floor; my job is nothing compared to the needless suffering they’ve consigned their dying parent to experience.

Shame on us for making dying foreign, and not the end of a life well spent.

An open letter to central line packaging engineers

Dear Sirs,

First, thank you for putting all the tools I need into one sterile package, minimizing the amout of running around finding little pieces to start central lines on my patients. (A central line goes into the central venous circulation, allowing the use of hypertonic medications and monitoring of venous pressures to guide fluid resuscitation).

Now, to my gripe: apparently none of you have thought about the order in which these devices are used when starting a line. Yes, everything has a special place, but it tells me you haven’t thought out the actual use of the kit when I have to dig the Seldinger wire out of the bottom of the kit despite its use being necessary very early in the process, and getting it out dislodges many of the other items from their pockets, then making the whole shebang a mess.

Therefore, I offer my assistance in designing a kit that makes more sense when it’s used.



FYI, here’s a nicely done animation of how to place a central line:

I do mine a little differently (direct sonographic guidance usually), but this is good for the gist. (The wire is there, but it’s really hard to see…).

Delusions of Benefit in the International Stroke Trial | Closer to the Truth

More TPa for stroke…

Delusions of Benefit in the International Stroke TrialResults of the largest and arguably most important trial ever of thrombolytics clot-busting drugs for acute stroke were published last week in The Lancet, and the study’s conclusions are breathtaking. Not because of the study results, which are unsurprising, but because the authors’ conclusions suggest that they have gone stark, raving mad.

via Delusions of Benefit in the International Stroke Trial | Closer to the Truth.

Well, that’s not good.

NYC painkiller poster

From NPR:

Doctors who follow the advice will consider alternatives to opioids and prescribe only a few days’ worth of the drugs, if they decide that’s the best course for short-term pain relief. They’ll also avoid starting patients on long-acting opioids, like Oxycontin, and will refrain from replacing lost, or allegedly lost, opioid prescriptions without lots of due diligence first.



I like it.

Press Ganey, meet Wong-Baker

For those not actively engaged in the practice of medicine, this will mean nothing to you. For those of us in the trenches:


I cannot wait for the day the government realizes this misguided effort is costing them Billions (and harming patients and providers).


ACEP 12 tweeting: Bukata and Hoffman

Those who don’t follow me on Twitter probably have calm, productive lives. Those who do wonder why I twitter at all. Because it keeps me busy and engaged, that’s why.

Here’s an edited compilation of two of the American College of Emergency Physicians Scientific Assembly 2012 lectures in tweets by me from Denver. These encompass about 3.5 hours of lecture by the same two legends, Jerry Hoffman and Rick Bukata reviewing the medical literature as it applies to EM.

I used Storify to put these together (it couldn’t have been easier). I left out a lot of comments from others, not as they weren’t interesting but as I’m trying to tell the story of this lecture.

At the end there’re some pictures of the Twitterers and Bloggers who get together after ACEP. Nice how we’re birds of a feather. For a bonus, at the end are Joe Lex’s 4 Rules of Emergency Medicine, which deserves its own compilation.

ACEP 2012 Tweets by me: Hoffman & Bukata

I went to the American College of Emergency Physicians Scientific Assembly held in Denver in October, 2012. I live tweeted some of the lectures I attended. Here they are.First, I’m going to combine the tweets from Hoffman and Bukata’s 2 lectures, as they’ll make more sense that way. Then pictures!

Storified by GruntDoc · Sat, Oct 13 2012 12:55:37

I’m going to start with my general Twitter disclaimer. I mean it.
Disclaimer: my tweets from #ACEP12 were paraphrasing, errors mine, don’t change practice based on reading tweets, do your homework.GruntDoc
And, off to the lectures:
HofKata: Trauma surgery is dooming their specialty going to the ER over and over for nothing surgical for them. #ACEP12GruntDoc
Referencing a European paper citing very very few went to the OR emergently from the ER to the OR, recommended calling TSS when the ER doc needs them, not a routine event.
(Will not catch on for a long time, Trauma needs their Activation Fee).
This following one had to do with ?whatever to do with those very tiny occult pneumothoraces we’re finding on trauma CT’s of the chest. Long, meandering discussion; sizes of the PTX weren’t defined, no criteria for getting a thoracostomy tube were made, just ‘did they get a chest tube or not’.
HofKata: discussion muddied as there is not a clear definition for want made the doc put in the tube to start with. #ACEP12GruntDoc
Not much was gotten from that article. Perhaps I missed the point.
HofKata: docs caught between doing what’s right for pt and right for doc; for doc getting test is right answer, not always for pt. #ACEP12GruntDoc
This next one tried to determine, in a ‘pan-scan’ for trauma ED, if there were some agreement on what trauma scans the ED attending and the Trauma Surgery attending could prospectively agree they didn’t need.

All the scans trauma wanted were gotten with a prospective form filled out by both about which scans they didn’t want. In the end the ED…

HofKata: wanted 30% fewer, and the TSS and EM in the end couldn’t decide about the value of the discovered incidentalomas. #ACEP12GruntDoc
They found a bunch of incidental things, and in the end couldn’t reconcile whether finding completely incidental things that didn’t affect management was worth the CT.
HofKata: factor VIIa is 10k for a 70kg pt in trauma and it didn’t help ( the non hemophiliac). Stop it. 97% uf use was off label. #ACEP12GruntDoc
HofKata: if you have 1 CT the likelihood is that you’ll have 5 in the next 5 years. Found a pt w 57 CTs. Wow. #ACEP12GruntDoc
The first CT is a gateway study to more, apparently.
HofKata: but when docs look at the same problem for themselves they typically choose less awful treatment, even if means pal care#ACEP12GruntDoc
Doctors will err on the side of survival in recommendations to patients, when they themselves often look at the data and decide they’d rather forgo some or all treatments and skip the unpleasant effects. Interesting.
HofKata: DC instructions. Pts have to understand, and they have to know when to come back. Ethical prob sending self limited prob #ACEP12GruntDoc
HofKata: to a referral, when its more cost for no benefit. #ACEP12GruntDoc
Bukata felt sending things like ankle sprains to PCP’s as a routine thing was ethically bad, as ‘it’s self limiting’ and costs the pt more for no benefit.
I disagree, many needs some Physical Therapy to have a more stable ankle that doesn’t recurrently sprain.

Also not a fan of these 9 page DC instructions we’re printing out.

HofKata: IO lines are great, and stop doing central lines because you can’t find a vein, use CL if need to measure things #ACEP12GruntDoc
HofKata: no need to give hydrocortisone if you use etomidate for induction. (Silly study). #ACEP12GruntDoc
HofKata: Tylenol w Motrin, and either alone. Point of treating fever comfort, not medical. No support to use both at the same time #ACEP12GruntDoc
HofKata: AAP specifically advises against using Tylenol then Motrin and alternating, confusing. Also, tells mom it’s a big deal. #ACEP12GruntDoc
treating pedi fever is about patient comfort, not treating disease. making a big deal out of fever treatment tells mom it’s very important, when it’s for comfort only.
HofKata: UTIs in small kids: can have asymptotic bacteruria and have a viral illnesses w fever and get dxd w uti. Cults have false+ #ACEP12GruntDoc
HofKata: 2-5% of kids have UTIs before puberty. Not happy about treating a ton. #ACEP12GruntDoc
Many of which were incidental findings, and the treatments can cause their own problems.
HofKata: study of 1,228 acute scrotii showed +creamasteric reflex w dxd torsion! 7% had NL or increased flow on US!? #ACEP12GruntDoc
Several people disliked my plural of scrotums being scrotii. I believe scrotae is the correct plural.
HofKata: test torsion, cont: advocates getting a iron consult for those w real sx’s and a negative w/u. Then cites anecdote. #ACEP12GruntDoc
uro(logy) got autocorrected here to iron, No idea why.
HofKata: study of Canadian hosp quick response teams. No difference. Things that seem reasonable often don’t work. #ACEP12GruntDoc
HofKata: several papers, PCR tests didn’t change abx rxing, CRP in URI resulted in 6 hour ED stays and no change in abx Rx, etc #ACEP12GruntDoc
Things being tried to tailor or eliminate antibiotic prescribing don’t. At least not in these studies.
HofKata: docs are reluctant to abandon disproven practices "ESP when lucrative". Most standards of care have never been studied. #ACEP12GruntDoc
HofKata: BNP for dyspnea in the ED. "Routine testing is of no benefit". Targeted okay. #ACEP12GruntDoc
HofKata: high sens Troponins: markedly higher positives, but 90% were causes other than AMI. (I don’t know want this). #ACEP12GruntDoc
Joe Lex ( @JoeLex5 ) commented on this later, ‘you mean low specificity troponins?”, rather than the as-spun high sensitivity. He’s right.
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
HofKata: stable angina, med mgmt vs stenting: medical therapy on top for everything x persistent pain. #aGruntDoc
HofKata: the US spends 150mil A DAY on angiosperm and stents, most never had a trial of med therapy. #ACEP12GruntDoc
Okay. for some reason the iPad autocorrect thought Angio meant angiosperm, which is weird. I don’t type well, things are flying by, and so I didn’t proofread that one before I hit send. (there were several comments later which I didn’t get, so didn’t play along)(It was busy in there, with all the tweeting and misspelling).
HofKata: shocker: STEMI pts needing transfer for PCI didn’t get transferred within 30 minutes. Median time was 64 minutes. #ACEP12GruntDoc
Bukata said they fixed this at his joint by having the same EMS crew that brought them in take them out, which was very fast, and with the right conversation EMS was all over it.
HofKata: if you can get to the cath lab in less than 4 hours its better than TPa. The 60 min rule for TPa is based on no evidence. #ACEP12GruntDoc
HofKata: then says he’d rather have TPa than stenting. (Weird). #ACEP12GruntDoc
The weird was mine. I don’t get that.
HofKata: 124k STEMI pts w CABG capability did cath then CABG 3%, without very rare. CABG grps did worse. #ACEP12GruntDoc
Wow, confusing tweet.
Issue was, is it safe to do caths in places that cannot do ‘rescue CABG”? In a study of 124K pt’s in centers with and without ‘rescue CABG’ ability, answer was yes, and in places that could do CABG it was done a whole lot more than places where it wasn’t; occasional pt had to be transferred to CABG place, but not many.
HofKata: ABCD2 score for stroke after TIA isn’t reliable. Another data dredging tool fails in real life. #ACEP12GruntDoc
HofKata: redefinition of Tia w MRI findings of infarct to stroke makes both groups look better: makes studies over time hard #ACEP12GruntDoc
Way more ‘strokes’ are now very minimal (what we used to call TIA’s) so the ‘stroke category looks better, and the TIA category looks smaller. Will confound studies looking both directions.
This next one it a review of IST-3, the never-ceasing desire to give TPa to every stroke no matter the time elapsed.
HofKata: IST-3 showed in a no blinded study using untrained family members as evaluators showed a tiny trend to improvement. #ACEP12GruntDoc
HofKata: IST-3 the first 300 pts evaluated by neurologists showed the tpa out to 6 hrs is much worse. #ACEP12 scathing editorials yesterdayGruntDoc
Family members, who knew whether or not their loved one got the TPa were asked by postal mail to evaluate their loved ones’ recovery, trended better for those who got TPa. Bizarre study bias built it. To say they were unimpressed would be an understatement.
HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12GruntDoc
“@gruntdoc: HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12” surprise surpriseJennie
HofKata: Geriatric and dizzy with a normal neuro exam will not have ICH. Based on a paper from 1998 w 4 pts found to have cblr bld. #ACEP12GruntDoc
There’s a practice that’ll be hard to change.
HofKata: no decent studies on ischemic stroke leaving BP up or the older lowering. Unless going to give TPa. #ACEP12GruntDoc
HofKata: kids w brain rumors typically represent w recurrent headaches, etc. authors rec scanning in kids w recurrent ha. #ACEP12GruntDoc
Means, don’t scan a kid on first HA or first week of HA.
HofKata:Canadian SAH CT study w 3rd gen scanner didn’t LP 50% of the pts in study. Gold std was pos CT. 30% lost to f/u. LP for SAH #ACEP12GruntDoc
HofKata: says Dr Newman who presented this paper yesterday as not needing LP is incorrect. #ACEP12GruntDoc
This could be ACEP’s first Pay Per View smackdown, Hoffman vs. Newman on this Canadian CT for SAH study.
HofKata: accumulating evidence quinolones can cause neuro sx’s. still safe drug as denominator is vast, but be aware. #ACEP12GruntDoc
HofKata: giving reglan over 15 vs 2 mins decreased the akathasia. 7% vs 26%. #ACEP12GruntDoc
Turkish study, makes sense.
HofKata: CO poisoning. Hyperbaric didn’t help, showed no benefit over high flow o2. Small study. #ACEP12GruntDoc
HofKata: studied on neurosurgeon, 1/2 sit vs stand on first postop visit. Again, pts like the seated visit. #ACEP12GruntDoc
Shocker here was that this was timed, it was these NS pt’s first post-surgical visit, and they lasted about a minute and 10 seconds. Wow.
HofKata: 8% of German studies eligibility criteria weren’t included in the paper,13 published modified info. Can’t extrapolate1/2 .#ACEP12GruntDoc
HofKata: 2/2 those findings to groups that were excluded. Theme is that funded studies seem to play fast and loose w reporting. #ACEP12GruntDoc
Throws a lot of what’s published into doubt, and when they don’t report excluded groups we assume their results are applicable for the general population, which isn’t correct.
What about the deep dive into the study information that’s given to the FDA from drug companies, that’s easily digestible, right?
HofKata: Cochrane authors report that it would take 2 FTEs 14 months to analyze, and found things never addressed in the papers. #ACEP12GruntDoc
The papers mean the studies that get publishe in journals. Not getting the whole story.
HofKata: Cochrane cont: the US FDA wouldn’t give the data, had to get from AUS. puts a lot of the publications in doubt. #ACEP12GruntDoc
This was about the new ‘high sensitivity’ troponins that are about to come out, for what reasons none of us in EM can discern, as it absolutely isn’t helpful…
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
Thanks, but I just tweet it. The glory goes to the lecturers, some were phenomenal. “@fayazg99: @gruntdoc fantastic stuff!” #ACEP12GruntDoc
Great coverage! RT @gruntdoc: That ends the lectures for me for today. Hope you enjoyed my coverage.Doc Gurley
@docgurley Awww, shucks ma’am. *tips hat*.GruntDoc
Meeting the social media twitter and blog greats at #ACEP12 @emcrit @gruntdoc @drrwinters @movinmeat @EMDocBrett http://pic.twitter.com/D6dLKId3Alexei Wagner
@JoeLex5 s 3 rules of emergency medicine:1) the nurse can hurt you way more than you can hurt themGruntDoc
@JoeLex5 s 3 rules of emergency medicine:2) you will never waken someone with narcan that you will like more awake than asleepGruntDoc
@JoeLex5 s 3 rules of emergency medicine:3) the LP target is always 1cm deeper than you think.GruntDoc
@JoeLex5 s 3 rules of emergency medicine:4) bonus: if you really don’t want someone to elope, hide their shoes.GruntDoc
“@gruntdoc: All the twitterers from #ACEP12 in one place. The rest of you are safe. For now. http://pic.twitter.com/j8i2uwb0” Wish I was there….realEDdoc

Colorado Mass Shooting Tested an E.R. Staff – NYTimes.com

Wow. Amazing.

AURORA, Colo. — More than three weeks have passed, but Daryl Johnson still begins his emergency room shift at the University of Colorado Hospital here with a sense of foreboding.

via Colorado Mass Shooting Tested an E.R. Staff – NYTimes.com.

And horribly frightening. I pray I spend my entire career and not have a night like that.

Chief Complaint of the night

[blackbirdpie url=”https://twitter.com/gruntdoc/status/234183229823922177″]

A ten year doc’s advice to newly graduated EM residents…

Recently, I blogged about being at my new job for 10 years. It was a wonderful experience to blog about stability. It’s also illuminating I’ve been here for 10 years and still call it my new job.

Not long after the blog post went up, I got an email from a soon to graduate Emergency Medicine resident who was curious as to what techniques I have used to stay at the same job for 10 years. This caused me some consternation, as I don’t think I really had an actual plan to be at the same place for this period of time. Emergency medicine practitioners are not known to stay in the same place for a long time, so blogging about a 10 year stay is something of an anomaly.

When I was a resident the common knowledge given was that it was important to serve on hospital committees, and to otherwise do a good job and you would be recognized and your life would be fine. This may or may not be true for everyone. I did find that I was on hospital committees, but it was after I’d been here for more than eight years and was interested in serving on them. One of the unusual things about my group is that there is extraordinary longevity, and I’m still basically middle of the pack having been here 10 years. I realize this is atypical for emergency medicine, but I think it will become more normal to have more job longevity as the emergency medicine field matures, and as there are more graduating residents.

What you’ll find helps you in the long run in emergency medicine is being a good colleague to the medical staff. This is somewhat antithetical to the way we’re trained, which is this low-level combat between departments, but ultimately the rainmakers talk to the hospital President, if your group isn’t making it some other group will. This does not mean you have to be a doormat but it does mean that when a consultant calls and asks you for a favor if it’s not unreasonable you should do it. This isn’t bad medicine, this is actually good medicine because you’re helping a smart colleague help out their patient. This service does not go unnoticed. In fact, if you want to stay in your place for a long time, be known to be helpful.

Being competent, you’d think, would be a given; you’d be wrong. Being competent in your job, and collegial with the nurses and staff, goes a long way to being accepted as one of the group and being one of the group means you get to stay.

Nobody wants their doctor to be having a bad day. Nobody who works there wants the ER doctor to be having a bad day. It doesn’t matter that your cat threw up in your shoes, or that your underwear is too tight, you have to try to get along. I’m not going to lie to you and tell you that I’m all roses and sunshine but I’m trying every day to get better at this.

Your reputation is set early, take advantage of that. I have a reputation for always being early; these days I’m about on time. For the first six months, I was about 10 to 15 minutes early for every shift. But, since I was always early initially, my reputation is set. On the same theme, as a colleague says, two minutes late is not on time, it’s very very late. When you’re working your tail off, you don’t want to be wondering when your relief is coming in. You’re very important; so is every single person you work with. Never forget that.

New grads are always interested in, and worry about, hospital politics. Here’s the short version of hospital politics in your first two years of practice: don’t make the directors’ job hard. That’s all you have to do. Just show up, work, practice good medicine, and don’t make the director’s job hard. The director is in that position for a reason; as a matter of fact, they’re so smart they hired you, so you should give them the benefit of the doubt when the iffy call comes out. They don’t want you to bother a certain specialist after a certain time; there’s a reason for that, and you should have a conversation behind closed doors, not at the nurses station.

And, when you do finally step in it, and make the mess that’s going to show up on the directors desk sooner or later, you need to be the one that has the conversation with the director first and they don’t need to hear about it from anyone else. This is basic leadership and you need to get on board with it. If they have the facts, and have your side of the story good or bad, they can help you; if they get called on the carpet and have to defend you not knowing your side of the tale, you will not come out the better for the experience. This is just the way of the world, it’s been the same way since you got punished for your brother knocking over the lamp. Help the guy who’s got to help you.

Also, when you show up, you’re going to be full of new knowledge. This doesn’t mean you’re smarter than the group, this just means you got out of training more recently. Use your new power for good and not for evil. And as you’ve probably guessed, there are about 30 ways to skin a cat, and you got trained in two. Keep your eyes open, and learn from your colleagues. They want to help you, let them help you.

Finally, have a life. Don’t spend all the money, put some away, as you may be like me and have to change jobs the first year. It happens. It happens to a lot of us; this doesn’t mean you’re bad it just means it was a bad fit. Keep trying.

Most of that was platitudes; sorry about that. The realty is if you’re a good person, do a good job, and play well with others you’ll be fine.


This was written with the new Mountain Lion operating system for the iMac; it was dictated and now you know that I don’t speak well.


Ottawa ankle rules and me

[blackbirdpie id=”223480429871767552″]

This reminds me of my experience with the Ottawa Ankle Rules in the Navy.

USMC Infantry is designed to generate ankle sprains, and recurrent ones. Initial sprains as young athletic hard chargers are required to carry big loads over unimproved terrain in the dark, plus seemingly all the time not in direct training was spent running.

The larger problem, and one I was educated on by a fellow BN Surgeon (who was a physical therapist prior to med school) while in Okinawa is that there’s no ankle rehab after a sprain. As soon as you can run on it you do, despite having torn stabilizing ligaments and not having done the training and exercises to get the ankles’ accessory stabilizers up to speed. Then, another sprain. The story of how our medical department got this fixed later.

Sick Call was musculoskeletal city with daily ankle sprains, which by that time in the Marines were usually recurrent. About a year into my assignment, out came the Ottawa Ankle Rules. After a year of negative x-rays, finally, a clinical tool to cut down on useless imaging! I used it in practice, taught it to the Corpsmen (who also found it usable and liked it) and our x-ray utilization dropped hugely and AFAIK we didn’t miss any significant fractures. I was proud.

I was moonlighting (for free, I was that bored) in the Camp Pendleton Naval Hospital ED, and mentioned my new practice and how I was proud to have made an impact.

The response: Please stop doing that. Now when they get off duty they drive down here to get an x-ray”.

Humbled, we backed off a little, but not much.

My response to the above tweet (which I now think I recall as being an @nickgenes original) was “Canadians get exams, Americans get x-rays”, which sums it up nicely.


ABEM ConCert prep course recommendations?

This is my renewal year for ABEM, and as you can imagine I just want to take a $1,700 test once (you read that right, that’s my cost to voluntarily take a test to remain Board Certified). (Board Certified rant pending).

What have other ABEMers taken, either as in-home or travel-to courses that you’d either recommend, or scare me away from? I’d actually prefer a travel-to course (fewer distractions), but am open to whatever works best.

Please add a comment, or send me a message through the ‘contact’ form.

I’ll let you know how it comes out.