December Fpnotebook Updates

Its been a while since the last post. November and December were busy months at the FPN homestead.

I’ve started logging all Family Practice Notebook updates. 25 major topic updates in December. Not only is the list of updates more complete now, but I’ve stepped up the number of resources reviewed monthly.

December also saw a new, re-vamped look to the Fpnotebook website with some added functionality. Let me know what you think.

Many more topic updates are ready for January release. And in April 2014, I expect to release an Iphone and Android version.

Have a great new year.

Posted in Medicine

September 2013 Fpnotebook Updates

I started work with atmoapps (programmers of the Tarascon mobile app) on native mobile app versions of fpnotebook.  These are planned for release in the first quarter of 2014.  To allow for a more automated demonstration of highlights from site updates, I am creating a new topic in fpnotebook “fpnotebook updates” which will appear in late October.  


It was a busy month of reading (about 40 hours on 20 review articles), but here are the highlights.  Intensively updated the airway chapter: based on attending Dr. Levitan’s Practical Airway course in Baltimore, MD.  Great course.  


Was surprised at how little I remembered about Pituitary Adenomas.  Updated at


Also updated the hernia section at based on Critical Decisions in Emergency Medicine.


September Em:Rap was as usual chock full of new information, but pediatric cardiology was particularly an intense listen/read:

Crashing Newborn:

Congenital heart disease:


Prescriber’s Letter had various medication precautions (Ketoconazole, Mefloquine, Plavix after CVA) and possible risks (more hype than data) regarding amlodipine and fish oil.


Posted in Uncategorized

A Challenging Day in the Emergency Department

They wait outside their ED room’s doorway, with their arms crossed.  A simple visit over, all but the discharge medication faxed, patient instructions added, discharge button clicked.  The visit started well with a pleasant conversation during the examination.  Evaluation efficient and appropriate.  But now they are waiting to go home, and their eyes are throwing daggers.   I could tell them I was interrupted on my way to the desk to complete their discharge. I could tell them I was interrupted by an elderly man who could not breath in Room 2, or chest pain in Room 3 or the clinic calling with a transfer and the radiologist calling with a new malignancy on CT.   But I simply apologize and repeat this cycle over and over again today.  Some days are like this.

One of the aspects of the emergency department that I find most challenging is patient flow in the midst of interruptions.  Critical patient arrivals, patient surges from triage, phone calls, asynchronous result review, documenting, RN questions and pharmacy clarifications.  In busy ED’s, this can amount to more than 10 interruptions per hour in some studies.  My interruptions do not come close to this, but I still at times feel overwhelmed.  

There were times when working clinic, I could fall an hour behind with work-ins and complex patients.  But my patients knew me and they would still be cordial to me despite the delay.   This is not always true in the ED.   I try to move fast, practice the best quality I know how, provide the best service I can and disposition as quickly as possible.  Despite this, they stand in their room’s doorway with their arms crossed angry that they are still waiting for discharge.  

In clinic, there was an overflow escape known as a schedule that would limit the flow of patients in.  On the worst days, there was still time for a sandwich and bathroom break.  There was still the appreciation for care from most of my patients.  

But today the emergency department surge continues.  It is on these days, that histories and exams are clipped and compressed and sign-outs to hospitalists are mediocre at best.   No time to open a reference or  consider a quality differential.  Hungry, fatigued and operating on clinical reflexes and base knowledge.  Small conflicts with sparks of dissatisfaction by patients and hospitalists.  I could explain the attempts at maximizing patient status over hours in the ED.  How I tried to stave off an admission, but this failed.  Now the family is frustrated with the long ED course, and the hospitalist sees this as a dump.   

So I continue to optimize my emergency department task juggling and patient flow.  But today as I leave the department, my shift over, I can still see a patient standing in their room’s doorway with their arms crossed and angry.   This was a challenging day.

Aside | Posted on by

Medical Informatics and Godel, Escher, Bach

In college I read (about half of) Godel, Escher, Bach by Douglas Hofstadter.  I understood less than 50% of what I read, and remember little now.  But I remember the challenge of trying to understand the “interweaving” of mathematics, art and music into common, recursive patterns.  It is a  transient glimpse into creative and brilliant minds, seeing information in awe-inspiring, unique ways.

  Medical informatics, especially my work on blends clinical science with programming/coding and design/illustration.  My trifecta – as enticing for me as Godel, Escher, Bach.

Outside of my primary job (Emergency Department and Epic optimization for our organization), I split my work on fpnotebook in half: medical note taking in the first half of the month and programming/designing in the second half.  

  As with the masters I admire in medicine, I have my mentors in coding and design.  My over-flowing book shelf has been augmented in the last few years with EM:Rap (Emergency Medicine) audio and Pluralsight (coding) and (design) videos.  I’m a voyeur of brilliant and creative minds.  Lessons in emergency airway management and bedside ultrasound, mixed with c# or javascript, with a side of photoshop, illustrator or 3DS Max.  Eclectic but uniquely satisfying.

Unlike Godel, Escher, Bach, medical informatics offers a challenge that is practical – an end result with utility.  With no shortage of project ideas, every month I have a 2 week opportunity for a creativity deep dive – blending what I’ve learned as an online apprentice.  Two weeks is an ideal project time frame for a solo developer – a sprint of creativity and immersion, without the fatigue, frustration and unwieldy nature of my prior year-long mammoth projects.  These small projects tend to build on others in a modular way and mistakes are made on a much smaller scale.

This month I created a stand alone search application for the website.  Those clinicians who tolerated my ramblings to this point, may wish to stop reading here.  The rest is in the form of notes to self, and to developers up too late solving that last infuriating problem, that should work, and wondering why Google has led them here instead of well traveled stackoverflow.

 The application is a single page application, served from mvc.   This allows for easy coding, compilation (js, less), web api, authentication, and deployment.  I like Typescript as well, but did not use it for this project.  Note to self – don’t forget to add to the web config:

    <modules runAllManagedModulesForAllRequests="true"/>

This is a data heavy application.  6000 pages, 4000 concepts, 20,000 titles with synonyms, and multiple maps linking topics to one another (in and out), as well as to concepts, keywords and the hierarchical tree the topics hang from.  

Complex data queries are my main focus for this project: how to filter topics in multiple ways. Ultimately (in a future 2 week project) I want to preview topic contents and their inter-relationships as well as to link custom user content. For this project, I needed to have easy access to processed site data for dynamic searches. I first made calls to the MVC controller, and then a web api, and then with odata queries.  All very seamless.  However, I kept thinking about how many times users would hit my server and database with over-lapping, inefficient queries.  That’s when I tried json files.

 I wrote a c# windows utility that queries the fpnotebook database and writes out the json to files using newtonsoft.  10 json files – most the size of small images or thumbnails (8 to 300 kb), 2 files at 1 mb each, and one file at 3 mb – in total less than 7 mb.   High bandwidth on the first download, but cached for a month until the data changes. Asynchronously loaded in a handful of seconds over a decent internet connection.

When loading json files with javascript, the parent directories will change on deployment; use server code to store the current parent URL path.

The application uses a themed version of bootstrap with angular-ui instead of the standard bootstrap plugins.  Angularjs and Typescript (along with jquery and underscorejs) are my favorite javascript tools.  Angular is tricky to write inside of Typescript.   But I like using angularjs for the view model and asynchronous data access and Typescript for the utility and business logic code.   Testing with jasmine works well in Visual Studio (with the Chutzpah plug-in).

So another 2 week development sprint is over and I’m ready to return to medical articles.  Next week I’ll attend the Levitan Airway course in Baltimore, kicking off another month of gently weaving together medicine with art and code.

Posted in Coding, Uncategorized

By the Way of the Door

“By the way”, as we are leaving the exam room, “I just wish my headache was not so much worse with coughing.” Brain stem mass.
“No doc, not in this part of the neck. I mean the swelling is here.” Lung cancer with supraclavicular node.
“Do you ever get a song in your head, you just cannot stop hearing.” Temporal lobe epilepsy.

The “by the way”, typically as we’re leaving the exam room, is a universal primary care daily experience. Weeding through the myriad of “by the ways” to pick out the uncommon or rare, hair-raising, sentinel finding seems an impossible task. But, over multiple encounters in successive years, primary care built clinical relationships help to hone the alarm system to fire when random clues arise that are discrepant with a patient’s established history. As long as I listen.

There lies the rub in the Emergency Department. No prior relationship, or worse a pigeon-holed prior relationship. Limited time to listen. Frequent redirection. Interruptions. Early boxing of histories into the chronic headache or low back pain container, or the multiple other reflexive responses to similar histories. Insufficient provider processing of histories recorded by scribes. Fatigue, especially towards shift end, especially over-night.

I have more reminders of bad acting illness in the emergency department. Looking for head bleed, abdominal mass, ectopic pregnancy, myocardial infarction has a high daily yield in the ED. So you memorize common pitfalls, decision trees. There is less gestalt and more guidelines, more decision-rule calculators. More advanced imaging and testing. But the history drives everything, and no abdominal CT will catch the CNS mass causing intractable vomiting.

Dr Mark Jaben “ranted” about this in EM:Rap – Talk to your patients.. His “rant” can be summarized in one word: Listen.

Posted in Medicine, Uncategorized

FPNotebook Update Highlights – August 2013

A few highlights from my August reading:
Tourniquets and Topical hemostatic agents from August 2013 Critical Decisions in Emergency Medicine (both links have the reference).

I do not see much in the way of massive uncontrolled bleeding, but better to read this now and store it away for some future date when I will be glad I read it. Topical hemostatic agents are not mainstream outside of the military, but would be great to have this around (wonder what the cost is? shelf life?)

Hypocalcemia, Hypercalcemia and Hyperparathyroidism from Parathyroid disorders in AFP.

How often I skip over the abnormal serum calcium, noting “need to come back to that” as I’m reviewing the metabolic panel. Nice algorithms in this paper for systematic approaches.

Finally, I never really thought about the acidity of IV fluids, but Scott Weingart of the EMCrit blog describes this on EM:Rap this month.
Here is my summary of what he said: Crystalloid acidity

Posted in Medicine, Uncategorized

FPNotebook Update Highlights – A New Series

I started taking medical notes on a handheld device (HP200LX) in 1994-1995, during my residency intern year. Throughout residency I took notes on everything: seminars, CMEs, rotation cheat-sheets, guidelines, articles, clinical pearls, books. By 1998, I created the fpnotebook website with these notes, primarily so I could access my own notes from anywhere. By 2001, I had a process to systematically update and reference the website. Since that time I have had a core set of review journals to read monthly in addition to CME conferences (IM/FP core, specialty, procedures), courses, certifications (ATLS, ACLS. PALS or APLS, NRP…).

To keep the site updated I spend ~40 hours/month reading a set of ~20 core medical articles in primary care, emergency medicine and pharmacy. I continue to attend as many as 4-5 CME conferences annually. The second half of each month is typically spent on 1-2 programming projects for web/mobile/desktop to either enhance the fpnotebook site functionality, or to write adjunctive software.

This month I am starting a new feature: monthly highlights from my medical reading/research. In this series I’ll try to point out some articles I found particularly interesting, counter-intuitive or just good reviews.

Posted in Medicine, Uncategorized