Grand Rounds Summary - July 29th, 2015

Grand Rounds Summary - July 29th, 2015

Morbidity and Mortality Pearls with Dr. Curry

Nephrolithiasis

Incidence in the US is 0.5-1% (lifetime risk 10-15%). There is a 2:1 male predominance and the recurrence rate is fairly high (37% at 1 year, 50% at 10 years and 75% at 20 years).

Patients at risk for poorer outcomes with ureterolithiasis are those with risk factors for diminished renal function, history of difficulty with stones/urologic intervention and symptoms of infection.

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Moonlighter - Recap

Moonlighter - Recap

This is our final recap of our "Out on a Limb" Case Series!  If you missed the initial "Moonlighter" case and discussion you can check it out here.  There were a number of great responses to the questions which we'll recap below.

Q1 - What are your options in handling this situation?

You have a few options in handling this situation. As many of the respondents chimed in, the wound definitely needs to be cleaned out and closed and the patient requires antibiotics as soon as is reasonably and safely possible, especially since the injury is already 6 hours old. The first option is to complete a sedation and multilayer repair in the ED yourself. As many people point out, this is not an excellent proposition unless there are extreme extenuating circumstances.

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Trouble Abroad - Recap and Commentary

Trouble Abroad - Recap and Commentary

The responses provided so far have been phenomenal, both insightful and provocative.  I am truly impressed.  As mentioned by several of my colleagues, many of these cases are deeply personal, not only because they involve highly vulnerable populations, but also because they may put clinical providers in harm’s way.  When we begin to discuss ethics, especially global health ethics, there is often no single correct answer to a given scenario.   We often deal with hard science and hard facts but sometimes you just have to go with your gut and do what you think is right.  If you missed the first case and initial discussion, check it out here.

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Grand Rounds Summary - July 22

Grand Rounds Summary - July 22

Dr. Miller - Leadership Curriculum

"Give me six hours to chop down a tree and I will spend the first four sharpening the axe" - Abraham Lincoln

In order to lead the team, you need a reflection of what you need to improve as a leader:

  • In a survey of academic chairs, communication, decision making, collaboration and trustworthiness were the top rated characteristics
  • In a survey of UC EM residents and faculty confirmed that these apply to every level of training
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Grand Rounds Summary - July 15

Grand Rounds Summary - July 15

Oral Boards

African Tick Borne Illness

  • Rickettsial illnesses (specifically Africae)
  • Empiric doxycyline & ID consultation for presumed tickborne illnesses
  • Rickettsia africae classically presents 4-7 days post exposure with thromobocytopenia and hyponatremia

Hypothermic cardiac arrest

  • Fixing the temperature is the most critical thing
  • EKG findings of Osborne waves in hypothermia
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The Little Things that Matter

The Little Things that Matter

We were fortunate, a couple weeks back, to have Dr. Brian Burns of Sydney HEMS come and speak to us.  In his lecture, “When the 1% Makes All the Difference” which you can find here, Dr. Burns hit on a number of excellent points.  We sat down and talked with Dr. Burns a bit more extensively over a couple of the themes of his lecture.

In this podcast, we cover some of the plus/minuses of checklists, the importance of high fidelity continuous training practices (simulation, routine case debriefing, intensive induction training), and the role of cognitive factors in running resuscitations.

Should resuscitations run like a jazz quartet or a Formula 1 pit crew?  Are checklists simply in the way or do they cognitively unload the team members to improve performance?  How do you train cognitive factors in resuscitation?

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When That 1% Makes All the Difference

When That 1% Makes All the Difference

Just prior to SMACC (the Social Media and Critical Care Conference), we were lucky enough to have Dr. Brian Burns of Sydney HEMS stop through Cincinnati.  In the video below you can see his lecture on when the 1% makes all the difference.  Dr. Burns talks about how we should strive for excellence in prehospital care not simply meeting minimum standards.  Watch the lecture below to hear Dr. Burns discuss the importance of incremental changes, cognitive offloading, checklists, and continuous improvement and training through simulation.

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Annals of B Pod - Summer Issue is Here!

Annals of B Pod - Summer Issue is Here!

In July, the entire emergency department is full of firsts; firsts shift in a new pod, first solo flights, first successful codes, and first shifts supervising new providers. This is an exciting time -- full of new faces and new roles. July can also be scary. All of those new roles come with uncertainty, fear of the unfamiliar, and immense responsibility.
This issue features cases and #lessonslearned from graduates whose “firsts” were not so long ago. These are showcased to serve as a reminder to us all that although this month is full of firsts for the residents, our faculty, nurses, and department have seen many Julys pass and are ready and eager to teach us their own #lessonslearned. Check out the new issue to see!

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"Flights" - Shaken Recap & Expert Commentary

"Flights" - Shaken Recap & Expert Commentary

Thanks to everybody who commented and contributed to the discussion on our final “Flight!”  If you missed out on the case, check it out here. Below you’ll find a curation of the comments to each question and a podcast with expert commentary from Jenn Lakeberg, APRN.  This was the final “Flight” for this spring/summer.  Look for the cases to return again in January 2016 as we begin Flight MD Orientation with the next class of future Air Care Flight Docs.

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Annals of B-Pod: #lessonslearned

Annals of B-Pod: #lessonslearned

Beware! Aortic Dissection

#lessonslearned is a case series submitted by former senior residents describing B-pod cases that taught them the art of medicine

Case 1

A male in his 30s with a past medical history significant for hypertension presented via EMS with pain all over, anxiety and shortness of breath. The EMTs reported that he had smoked marijuana about 30 minutes before his presentation from his normal supply. At the scene he was noted to be very agitated, diaphoretic and vocal about his pain. He was yelling that he was hurting all over, he was having trouble breathing, and that he wanted to be sedated. He states that he has never had problems like this.

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Interpretation of Cervical Spine CT's

Interpretation of Cervical Spine CT's

It's 6pm in the ED on a sunny summer afternoon- you're working as a single coverage physician at a level 3 trauma center.  You are noticing an uptrend in the trauma patients being brought in over the past few hours. While log rolling yet another patient, an EMS provider tells you that they have been making runs nonstop- all of the hospitals downtown are overloaded, and it doesn't look like it will slow down anytime soon. Your modest trauma bay is already full, and you're starting to sweat about the state of the department- there are 4 patients in the pod you haven't even seen yet, 2 with abnormal vital signs.

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Out on a Limb - Moonlighter

Out on a Limb - Moonlighter

You are a 4th year EM resident moonlighting on your first day in a remote area as the solo provider that has minimal availability to consulting services. The nearest major hospital is approximately 100 miles away.

A 5 year old child enters your ED at 3 am with a large, complex laceration to the face from a dog bite which will likely require sedation and a layered closure.  His injuries were sustained approximately 6 hours ago. The wound is complex and will require a multi-layered closure and there are a couple of areas of tissue avulsion. You have 1 or 2 cases of similar experience from approximately 1 year ago on your plastics rotation...

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Out on a Limb - Troubles Abroad

Out on a Limb - Troubles Abroad

You are an EM resident from the US working in a rural South African hospital as part of a global health elective.  The political climate is such that a prolonged government strike is leading to severe staffing and resource shortage.  There are no disposable gloves and many procedures are performed barehanded.  One day during rounds in the Labor Ward, the Chair of the department asks you to draw blood from an HIV-positive woman in labor as the team is presenting the patient in her room.  The only remaining gloves in the hospital are a few pairs of sterile gloves reserved for emergency cesarean deliveries.  There are high rates of HIV-exposure and many staff members are currently on post-exposure prophylaxis.

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Out on a Limb - "Is there a Doctor on Board?!"

Out on a Limb - "Is there a Doctor on Board?!"

You are enjoying a cocktail on the way to Hawaii on a well earned vacation when a voice comes aloud overhead, “Attention all passengers. If there is a doctor or health care provider present, we ask that you please come to the front of the plane immediately.” From your vantage point in the back of the plane, it becomes clear very quickly that no one is volunteering. You find yourself being stared at by a plane full of people as you make your way to the front, to find a morbidly obese Caucasian female with a flight attendant at her side. You start your encounter…

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Favorite Positions!

Favorite Positions!

Multiple casualties are brought to you from a house fire.  There are four victims:

  1. A 5’11” 70 kg woman with a GCS of 8
  2. A 5’9” 140 kg man with circumferential burns of the chest and neck
  3. A 20 month-old with a pedi-GCS of 10
  4. An elderly, 5’6” 65 kg man with no burns, but a history of severe CHF and complaining of chest pain and dyspnea

You determine that they all require intubation for various indications.  You choose RSI as the method for all except the morbidly obese patient, who you intend to intubate awake, with sedation and topical airway anesthesia.

Question:

How would you position each of these patients to optimize your chances of successful intubation on the first attempt?

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Global Health Case Files

Global Health Case Files

Imagine:  you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria.  You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics.  Your clinic does not have any power.   Your diagnostics include:  urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria.  You have 2 nurses, one of whom acts as a translator (from Swahili to English).  You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.  

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Endotracheal Intubation vs. Supraglottic Airway Placement for Out-of-Hospital Cardiac Arrest

Endotracheal Intubation vs. Supraglottic Airway Placement for Out-of-Hospital Cardiac Arrest

If you want to get a group of prehospital providers riled up, simply ask them how the airway should be managed during out-of-hospital cardiac arrest.  "Supraglottic airways are easier!"  "No, you gotta stay with endotracheal intubation!"  "Forget advanced airways, a bag-valve mask is all you need!"  "Only apneic oxygenation!"  Don't believe me?

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Flights - Shaken

Flights - Shaken

You are sitting on the helipad during your UH shift talking with the flight nurse when the tones drop for a pediatric scene call.  You gather yourself after you have that crap your pants moment that everyone has with pediatric scene calls and whip out your smart phone with your pediatric application of choice.  You begin to write down doses and sizes on your tape on your leg based on the report of the patient’s weight from the providers on scene.

You land in an elementary school parking lot to the delight of the children at the local school.  Cars begin to slow and pull over as you exit the helicopter and walk to the squad.  You walk to the side door of the ambulance and find 6 EMTs crammed in the squad.

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