Grand Rounds Recap 4.17.19

Leadership curriculum: Conflict resolution WITH DRs. leenellett and mcdonough

Navigating Difficult Conversations

  • Know yourself (consider a DiSC profile)

  • Know the objectives of the person with whom you are having a discussion

  • Bring or model your behavior after a role model

5 Strategies for Dealing with Conflict

  • Flight Response (Avoidance, Silence, Sarcasm, Withdrawal) - This has the most potential for misunderstanding as your body language frequently does not mirror what you communicate verbally

  • Accommodation- This can lead to resentment if employed too often

  • Fight or Violence (Controlling, Name calling, Attacking)

  • Compromise- Leaving the conflict with both parties agreeing on partially fulfilled needs

  • Collaborate- Discuss the different issues with the persons and come up with a Win-Win

Rules of Conflict Resolution

  • Reflect before you begin

  • Seek first to understand

  • Come up with a shared goal- What do you want from them? What do you want for the relationship?

How to Implement a Shared Goal

  • Create trust

  • Focus your attention on them

  • Be open to discussion

  • Their perception affects your reality

  • Determine the goal before looking for solutions

Navigating a Difficult Situation

  • Effectively listen

    • Use open rather than closed questions

    • Use a reflective response to reiterate the point they are trying to communicate

  • Separate the person from problem

  • Focus on “I” statements of fact rather than “you” statements of opinion

  • Acknowledge others’ contributions

  • Avoid Always and Never statements

  • Focus on solutions that satisfy their needs, and be okay with a compromise or a new solution

What if None of That Works?

  • Keep your eyes on your ultimate rather than your immediate goals

epistaxis WITH DRs. li and iparraguirre


  • 450,000 patient visits per year in the ED for epistaxis, with the majority of patients being discharged home

  • Uncomplicated vs. Complicated

    • Uncomplicated epistaxis is due to mucosal irritation, URI, sinusitis, allergic rhinitis, or trauma

    • Complicated epistaxis is due to anticoagulation, thrombocytopenia, drug abuse, or structural abnormalities

  • Anatomy

    • 70-95% of nosebleeds are anterior at Kiesselbach’s plexus and tend to bleed from one nare

    • Posterior source bleeds are more difficult to visualize and tend to bleed from both nares

Hypertension and Epistaxis


  • Assess airway, breathing, and circulation to determine stable or unstable

  • Have the patient blow their nose to get rid of the excess blood and unstable clot

  • Administer an alpha agonist to constrict the vessels (Oxymetolazine vs. Lidocaine with Epinephrine vs Cocaine)

  • Apply direct pressure for at least 15 minutes with a nasal clip or having the patient apply appropriate pressure


  • Diagnostics should be individualized based on history and physical exam

  • CBC can detect thrombocytopenia or acute anemia from hemorrhage

  • Coagulation studies are not routinely recommended



Anterior Packing

Posterior Packing


R4 simulation WITH DRs. colmer, harrison, mckee, and continenza

Left Main Coronary Acute Myocardial Infarction Simulation

Left Main Coronary Acute Myocardial Infarction

Thrombolytics in Acute Myocardial Infraction

  • Thrombolytics are a second line treatment of STEMI compared with PCI as they have a lower efficacy

  • Thrombolytics are indicated if time to PCI is greater than 2 hours from medical contact

  • The decision to give thrombolytics should be made within 30 minutes of patient evaluation

Pediatric EKGs

  • Juvenile T-Wave patterns

    • T-Waves in V1-V3 can be inverted because the RV:LV ratio is higher in pediatric populations

    • 0-7 days, V1-V3 should be upright

    • 7 days- 8 years V1-V3 will be inverted, and sometimes in V4

    • T-Waves should NOT be peaked and upright, flattened, or have large, deep, symmetric inversions throughout

  • Sinus Arrhythmia

    • Variation in P-P interval, without variation in the P-R interval

    • This is benign and a normal variant, not requiring intervention

  • Congenital Long QT

    • Machines cannot calculate QT as accurately at higher rates, so manually calculate your QT in pediatric patients

    • This is the most commonly missed arrhythmia in pediatric patient

    • Normal in 0-6 months of age is <0.49 seconds

    • Normal in 6 months of age is <0.44 seconds

    • Treatment in pediatric patients is beta blockers or AICD. Beta blockers will prevent adrenergic surge and tachycardia, preventing fatal arrhythmia.

  • Brugada Syndrome

    • Most commonly present in adolescent or early adulthood rather than very early ages

    • Also more common in patients that present with a fever and syncope concurrently

    • There are 3 different morphologies of Brugada

  • Wolf Parkinson White (WPW)

    • In the case of PR shortening, search for a delta wave

    • A delta wave must be identified to diagnose WPW

    • Beware retrograde P-waves burying themselves within the T-wave complex

  • AVRT

    • This is due to an accessory pathway connecting the atria to the ventricles

    • AV nodal blocking agents are contraindicated as it will force the electrical impulse down the accessory path

    • Procainamide is a first line treatment for this arrhythmia

  • Supraventricular Tachycardia

    • Vagal maneuvers are first line treatment for stable SVT, and include ice to the face in infants vs. valsalva in older children

    • You must hold the ice on the infants face up to 20 seconds to stimulate a diving reflex

    • If these fail, adenosine can be given in 0.1 mg/kg for the first dose, 0.2mg/kg for the second dose with max being adult dosing

  • Benign Early Repolarization

    • Up-sloping ST segment is reassuring

    • Your ST segment amplitude compared to your QRS height should be <25% in benign early repolarization

See an in depth review of normal pediatric EKG’s on TamingTheSRU here!