Behind the Scenes


Meet Jack, a Web Application Developer for Techies Without Borders.

“At first, it’s my graduate classmate joined this team and asked me to join and work with her in May of 2016, even though she left the team because of private reason, I am happy that I am one of the members of the project.

It’s also my first opportunity to work in this kind of project for helping people in resources poor area in other countries. All of us in the team have been working and cooperating hard in what we are responsible, and we also had
meetings many times even some of us is in different time zone.
I also want to say thank to Dr. Li and Dr. Thomas. You really did very well in leading us and gave us many suggestions on the problems I faced and continued to let me work with you even I’ve come back to Taiwan.
Finally, I hope this project can help as many people in world as possible.”
“I am mainly responsible for building Continuing Medical Education on Stick (CMES) admin panel for the team to create and edit topics. In the beginning, the features were simple and had many things to be improved; by our hard work and cooperations little by little, the panel was upgraded to V2 version and the Spanish version is also now supported.
I am really happy to see this good result for CMES project.”

Behind the Scenes

Over the next few months, I will post about the creative and dedicated Techies Without Borders (TWB) IT team that makes CMES and CMES-Pi possible. They donate their talent and time because they believe in you and the CMES mission: providing current cme for doctors and nurses in resource-challenged countries with our partner Emergency Medicine Reviews and Perspectives (EMRAP).

Meet Ben Yu, Web Application Developer. During March TWB partnered with Timmy Global Health to provide CMES and CMES-Pi to their partner clinics in the Dominican Republic and Guatemala. This required creating a Spanish version of all our products. Ben had this to say:

“We did all the translation preparing the USB version and packing the exe, for the CMES-Pi as well. We also regularly updating the Spanish version to make sure that everything is on point and working. At last, we did a few backend changes to make user’s usability more fluid.”

Microsoft Azure Award for Techies Without Borders

Wikimedia Commons photo.

Microsoft Azure Sponsorship has been granted to continue cloud-based support for Techies Without Borders and the Continuing Medical Education on Stick (CMES) and CMES-Pi project. All of us appreciate the support from Microsoft and special thanks to Dr. Yan Li for her diligent application.

Microsoft Azure is a broad set of cloud services. IT professionals and developers use Azure to build, deploy, and manage applications through Microsoft’s global network of data centers. Azure provides integrated tools, DevOps, and a marketplace to support developers in building a variety of needed platforms from simple mobile apps to internet-scale solutions.

HEART Pathway

Valentines card (photo Wikimedia Commons)

Valentines Day is this week on February 14th. What better time to review the HEART Pathway for your patients with chest pain.

(Photo PubMed Commons)

Check out the podcast or pdf on how one community hospital incorporated it into their electronic medical record (EMR) in the February EMRAP podcast: HEART in EMR; by Rob Orman MD and Peter Smulowitz MD. Don’t use EMR at your facility…leave a comment and tell your colleagues how you would use it in your practice or at your facility.

Who knew? In 1835, 60,000 Valentine cards were sent by post in Britain, despite postage being expensive. (Wikipedia)



Push the Pause Button

(Wikimedia Commons image)

Several years ago my team and I resuscitated a two-year-old child with fulminant meningococcemia during a night shift in a small community hospital. It was only my second case in 25 years of practice, but despite providing all the right lifelines and transfer to a tertiary care facility with a pediatric ICU…I knew the child would die.

We carried on with our duties long after the helicopter departed…steadfast yet each of us enveloped in our own sadness. It wasn’t until weeks later during the “debriefing” meant to cleanse our hearts and minds of the tragedy did we dare face the death together as a team.

I can tell you from experience this is not the way to approach a death of this magnitude…or any death. Take a short listen or read about initiating “The Pause” after a death no matter where you practice by listening to: The Pause by Reuben Strayer MD on the February EMRAP cme.

Who knew? Ever wonder where those computer symbols originated? According to Gizmodo, the pause symbol is based on a musical notation, the caesura, which indicates a-wait for it-pause.



Hyperbilirubinemia: Mellow Yellow Isn’t Just a 1960’s Song

Phototherapy for neonatal jaundice. (photo courtesy Wikicommons)

Hyperbilirubinemia: one of the most common problems seen in term newborns and warrants a periodic review to refresh our knowledge base. Consider this case: A well-appearing infant presents and is jaundiced. The baby has a cephalohematoma and is breast feeding. Everything else is fine. The child is eating well and urinating. Do you still need to send labs?

Take a listen to the MP3 podcast or read the PDF in the January EMRAP podcast: Hyperbilirubinemia by Rob Orman MD and Tim Horeczko MD.


Who Knew? Jaundice was observed for centuries but the earliest medical literature was by Jean Baptiste Thimotee Baumes (Baumes, J. 1806). This description was published as a chapter in a book entitled: Traite de L’amaigrissemwnt des enfans. Christian Schmorl in Dresden was the first to coin the term “Kernicterus” in 1904.



Pneumonia Reboot: Admit or Discharge Decisions

CXR of a 37-yr-old male with pneumonia and abscess. (Photo from Wikicommons).

CT scan of the chest showing bilateral pneumonia with abscesses, effusions, and caverns. 37 year old male. (Photo from Wikicommons)

The case as presented in the January 2018 EMRAP files:

A 73-year-old male with a history of hypertension, hyperlipidemia and aortic stenosis presented with cough, fever and sputum. He was mildly tachycardic but not tachypneic and was well-appearing. On lung exam, he had some focal wheezes in the left lower lobe. Swaminathan thought the patient had pneumonia. Chest x-ray confirmed a left lower lobe infiltrate.

Now what? What else do you need to know about this patient that impacts discharge planning. It’s flu season here in the USA, the ED and wards are filled with critical patients and beds are in high demand. Do you really need to admit this patient? Tie up a bed? Expose him to hospital-acquired infections?

Listen to the January EMRAP Introduction podcast or read the PDF by Rob Orman MD and Anand Swaminathan MD to find guidance and opinions.

Who knew? The CURB-65 and the PORT Score can help you make these difficult decisions.

Osteomyelitis: The Diabetic’s Skeleton in the Closet

Femur. Osteomyelitis. From ancient cemetery, Chicama Valley, Peru ; (Photo courtesy WikiCommons)

X-ray osteomyelitis 1st metatarsal joint (photo courtesy WikiCommons)

Do you admit all your diabetic patients with suspected osteomyelitis? Do you need to?

Is it acute or chronic?

Do you need to culture all diabetic foot ulcers?

What two entities will help identify patients at risk for osteomyelitis? The answer may surprise you.

Download from CMES the podcast or PDF for the December EM:RAP Diabetic Foot Ulcers by Matthew DeLaney MD and Charles Khoury MD and share your experiences or recommendations by leaving a comment.


Who Knew? Evidence for osteomyelitis found in fossil records are studied by paleopathologists, specialists in ancient disease and injury. It has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis.

Life Threatening Bleeds in Oral Anticoagulated Patients

Noval Oral Anticoagulant (NOAC) medications. Travelers like the convenience because they don’t need monthly blood tests. It also means they show up in your emergency departments and clinics from all over the world with minor and major bleeds. How do you know what reversal agent to give or even if there is one? Perhaps they can’t recall the name or a friend is watching their belongings at the hotel.

Check out the December Annuals of Emergency Medicine podcast: Reversal of NOACs by Jessica Mason MD, Andy Grock MD and Annahieta Kalantari DO. The simple answer may surprise you.

Who knew? Hirudin extracts from the medicinal leeches were first used for parenteral anticoagulation in the clinic in 1909, but their use was limited due to adverse effects and difficulties in achieving highly purified extracts. Published by NCBI PubMed 2012 Jun 1;9(2):83-104.


Standard Oxygen Therapy Ignites Controversy

Does oxygen therapy make a difference in heart attack patients?The European Society of Cardiology, news release, Aug. 28, 2017 cited this Swedish study which found no difference in patient outcomes.

EM:RAP has up-to-date information about using oxygen therapy in the acute setting. So hold your breath and check out these podcasts:

Paper Chase 2: The Oxygen Middle Path by Sanjay Arora MD and Michael Menchine MD

Introduction: Flush Rate Oxygenation by Rob Orman MD and Anand Swaminathan MD

Did you know?  Oxygen was discovered independently by Carl Wilhelm Scheele, in Uppsala, Sweden in 1773 or earlier, and Joseph Priestley in Wiltshire, England in 1774, but Priestley is often given priority because his work was published first. Priestly fled to America in 1793 to escape political persecution. The Joseph Priestley museum is in my hometown Northumberland, Pennsylvania USA…I’ve never been there.



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