Grand Rounds Recap 7.12.17

Breaking Bad News with Dr. McDonough

  • In the Emergency Department, we are often the bearers of bad news.
  • We frequently must discuss death, acute critical illness or medical errors.
  • We do this under less than ideal circumstances: we often do not have a previous relationship with the patient or their family, the patient's condition may have changed rapidly, or you as a provider are pulled in multiple directions.

Case One: A previously healthy 55 y/o male who sustained an out-of-hospital cardiac arrest and could not be revived in the Emergency Department.

  • Be direct yet empathetic. Sit down with the patient's family. It's ok to say you're sorry.
  • Use clear language. It's important to convey that the patient died.
  • Social Work and ODA are great resources. They can help with identifying key family members, understanding the family's level of knowledge about the patient's condition and helping to answer a family's next questions.
  • Be aware of your own personal safety when giving bad news in contentious situations. 

Case Two: A 55 y/o male with progressive left arm weakness for several weeks who was found to have a cerebral mass with edema.

  • Avoid using confusing medical terms with patients or their families. People may not know what a "mass" means.
  • When there is diagnostic uncertainty, you must convey your concern regarding their potential diagnosis ("I am concerned this could be cancer.") but don't give a definitive diagnosis if you are unsure.
  • When you are going to deliver bad news, make sure the patient is comfortable with everyone in the room hearing the results. 
  • Avoid discussing prognoses or predictions; leave this to the managing services who can make definitive diagnoses.
  • Having a plan going forward is important! Make sure to discuss the next steps with the patient after discussing the findings ("We are going to admit you to the hospital and have our neurosurgeons see you.").

Case Three: A 75 y/o female who presents with urosepsis. She has an anaphylactic reaction to Ceftriaxone, briefly codes and requires a cricothyrotomy. It is later found that she had a listed allergy to this antibiotic. 

  • It is important to address and acknowledge the error up front. Don't make the patient's family ask why something happened.
  • Families will want to know that an error is taken seriously and won't happen to another patient. Discuss what steps will be taken going forward to make sure this is not repeated.
  • Patients want compassion and most will want to hear an apology. While dependent on local law, in many states an apology is not considered an admission of guilt.

Obstetric Trauma Sim with drs Teuber and Renne

The Case: A 29 year old pregnant female involved in a high-speed MVC with a prehospital GCS of 7 with vitals notable for tachycardia to the 120s, RR 28, BP systolic 90, O2 sat of 90% on NRB. Upon arrival to the ED, the patient is a GCS of 4 and her vitals are notable for a BP of 80s/50s. Her exam is notable for a left pneumothorax with tension physiology, which is decompressed without improvement in her hemodynamic instability. She is then given blood and a pelvic binder is placed, but devolves into a PEA arrest. A resuscitative hysterotomy is performed and the mother obtains ROSC.

  • In general, what's good for mom is good for baby -- focus on the care of the mother first.
  • The initial evaluation in the unstable, pregnant trauma patient is unchanged from our standard practice; perform a primary survey while assessing for life threats, obtaining appropriate initial diagnostics (e.g., CXR, FAST) and perform appropriate interventions as indicated.
  • If a fetus is known or thought to be viable (>20 weeks), a resuscitative hysterotomy (also known as a peri-mortem c-section) can be life-saving for both the mother and the fetus. Time is of the essence; this should be done as soon as possible after the mother arrests for the best outcomes.
  • After a resuscitative hysterotomy, the mother and the baby are resuscitated as usual per ATLS and PALS. 

Oral Boards Case with dr Stettler

Case One: A young female in a high-speed MVC who is complaining of abdominal and back pain. On presentation, it is found that she is approximately 8 months pregnant. Her primary survey is intact; secondary survey reveals a tender, gravid abdomen with a seat belt sign. Her workup is notable for a FHR of 130 bpm and a negative FAST. GU exam reveals bright red blood at the introitus. The patient goes on to develop a petechial rash at the site of her blood pressure cuff. Her labs are notable for thrombocytopenia, an elevated INR, a decreased fibrinogen and an elevated lactate.

  • Initial evaluation of the pregnant trauma patient should focus on the mother and the ABCs. 
  • In the hypotensive pregnant trauma patient, decompressing the IVC by putting the patient in the left lateral decubitus position can be helpful if the patient does not require spinal immobilization.
  • Placental abruption is one of the most feared complications of maternal trauma. It can lead to consumptive coagulopathy and DIC, fetal demise and maternal morbidity or mortality. Emergent c-section is indicated in these patients if the fetus is viable. 
  • Rh negative blood (O-) should be given to pregnant trauma patients until a type and screen is obtained; the patient will likely go on to require FFP, platelets and/or cryo.
  • Rhogam is important for any pregnant trauma patients who are Rh - and have signs of bleeding.

Skill stations with dr dang

  • Shoulder Dystocia
    • An arrest of labor due to failure of the anterior shoulder to pass below the pubic symphysis; seen in less than 1% of all vaginal deliveries. 
    • McRoberts maneuver: hyperflexing the mother's legs with suprapubic pressure.
    • Rubin II maneuver: pressure on the anterior shoulder.
    • Woods' screw maneuver: 180 degree rotation of the fetus to see the posterior shoulder, and then delivery of that shoulder.
    • Gaskin maneuver: mother on all fours with back arched, serving to widen the pelvis.
    • Intentional fetal clavicle fracture: a procedure of last resort.
  • Frank Breech
    • The most common type of breech presentation; hips are flexed, knees are extended (in the "pike" position).
    • Occurs in 3-4% of deliveries. If known, a c-section is indicated for delivery.
    • If precipitous in the Emergency Department, there are some maneuvers that can assist the provider.
    • The Zavanelli maneuver involves pushing the presenting fetus back into the vagina, which can temporize the delivery until help arrives; this can be augmented with tocolysis.
    • The Pinard maneuver involves allowing the fetus to deliver to the level of the umbilicus, and then exerting manual pressure on each knee to force them into flexion; the leg is then swept medially and out of the vagina. The fetus is then allowed to deliver, rotated 90 degrees, and the anterior arm is swept forward and delivered. The fetus is then rotated again, and the other arm is delivered. Then the head is delivered. This can be used with an episiotomy as well.
    • Make sure to evaluate for prolapsed cord and rupture of membranes.
  • Cord Prolapse:
    • A potentially life-threatening condition with an incidence of 0.1%-0.6%; often seen with breech deliveries.
    • Do not manipulate the cord; keep the cord warm and moist.
    • Position the mother in Trendelenburg position to use gravity to your advantage .
    • Manually elevate any presenting part; consider loading the bladder via Foley with NS can help relieve pressure off the cord.
    • If fetal bradycardia is present, consider tocolysis, fetal monitoring and cord reduction as a last resort.