Grand Rounds Recap 7.20.22
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Leadership Curriculum: Receiving Feedback WITH Dr. Hill
“There are no two words in the English language more harmful than ‘Good Job’.”
What makes receiving feedback challenging?
Can be emotionally and cognitively challenging
Can be hard to approach in a constructive manner
Causes of difficult feedback
Truth Triggers = set off by the substance of the feedback itself
Try to understand what type of feedback is it?
Appreciation
Recognizing and rewarding
Coaching
Helping expand knowledge
Evaluation
Where do you stand globally
Johari Window
Blind spots = not known to self and not known to others
Arena - known to self and known to others
Facade = known to self and not known to others
What type of feedback was I looking for?
Relationship Triggers = Relationship to the person offering feedback impacts feedback received
Switchtrack Conversations = change topic to how we feel after we receive feedback and end up talking past one another
Identity Triggers = something about feedback shakes our identity
Be mindful and prepared
Understand your reactive behaviors to criticism
Inoculate yourself against the worst
Notice your reactions in real time
Move Towards a Growth Mindset
Aim for Coaching
Find items that are actionable, specific and concrete
Clinical Decision Rules WITH Dr. Zalesky
Clinical decision rules take known patient information and translate it into actionable probabilities of disease
Steps to create a decision rule:
Find a data set and extract the data as it applies to a clinical outcome
Internally validate these data within your population
Externally validate it; apply to a new set of patients
How do we assess decision rules?
Direction
Unidirectional (rule out disease)
Distills into one piece of information
PERC
Stratify (stratification of probability ie. high/med/low)
Distills into multiple levels of information
HEART score
Bidirectional (yes/no)
Ottawa Ankle Rules
Population
Who can we apply this rule to?
Purpose
What was it built for?
Validation
Does it work?
Application to Oakland Score
Stratify risk for Lower GI bleed
Direction
Stratify
Population
ED patients with bright red blood per rectum
Derivation study in UK, validated in the US
Purpose
Inform discharge
Validation
Yes - internal and external
Must calculate the score correctly
HEART score
Application of ‘high risk features’ is heterogeneous in practice, but is specifically defined in the derivation study
Canadian HCT Rules
Limited when applied to intoxicated patients as subsequent studies are taken into account
R3 Taming the SRU: BRASH Syndrome WITH Dr. Fabiano
BRASH Syndrome (Bradycardia, Renal failure, AV-nodal blockade, Shock, Hyperkalemia)
Bradycardia
AV nodal blockade, usually in the setting of medication use and AKI
The EKG and hemodynamic effects of hyperkalemia in the setting of AV-nodal blockade with BRASH syndrome are disproportionate to the K+
Usually, HyperK+ does not cause bradycardia until K+ is > ~7
Can be seen much earlier in BRASH syndrome with synergistic effects from AV-node blocking medications (hyperkalemia is usually more moderate)
May also not see the classic peaked T-waves of hyperkalemia
Treatment
Treat hyperkalemia
Calcium
Insulin/Dextrose
Albuterol (also benefit for bradycardia)
Chronotropy, inotropy, renal perfusion
Epinephrine
Low threshold to start a drip
Consider isoproterenol if epinephrine fails for increased chronotropy
Assess volume status and address on an individualized basis
Diuresis (kaliuresis) with potassium wasting diuretics and repletion of volume as needed with isotonic crystalloid
Unless already progressed to oliguric renal failure, these patients rarely require emergent dialysis
Rarely do these patients require temporary pacing
R4 Case Follow Up: Cryptococcus Meningitis WITH Dr. Ijaz
Cryptococcus Meningitis (CM) in HIV
223,100 global cases annually
81% mortality
Risk Factors
HIV
Solid organ transplant
Chronic glucocorticoid therapy
Hematologic malignancy
Presentation:
Neck pain + fever + AMS < 50% of meningitis
Most common:
Headache
Neck stiffness
Fever
AMS
Cryptococcus Meningitis: AMS, Headache, NV, visual changes, CN VI Palsy
Neck stiffness presents in <20% of cases of CM
Physical lacks sensitivity
Kernig’s sign: 14% sensitivity
Brudzinski’s sign: 11% sensitivity
Nuchal rigidity: 39% sensitivity
Fungal: gradual onset, delayed presentation
2wk in HIV+
6-12wk in HIV-
Viral: mean 2d presentation
Bacterial: <24hr presentation
Treatment
Induction: 2 weeks rapid CSF sterilization improved survival rates and decreased relapses
IV Amphotericin B + PO Flucytosine
Consolidative: 8 weeks
PO Fluconazole
Maintenance: 1 year
PO Fluconazole (lower dose)
Oral Boards WITH Drs. Lang and Nagle
Aortoenteric Fistula
Development of an abnormal communication between the abdominal aorta or an abdominal aorta graft and a portion of the bowel, usually the fourth portion of the duodenum
Primary fistulas arise from atheroscleotic AAA or infectious aortitis (commonly syphilis, TB)
Secondary fistulas arise from pressure necrosis or graft infection after prosthetic aortic graft
Presentation:
Classic Triad (present in < 25% of patients)
GI bleed
Abdominal Pain
Pulsatile abdominal mass
Patients with infected grafts may exhibit signs of sepsis
Shock can result from hemorrhage or sepsis
Diagnosis:
Patients with high clinical suspicion should go to the OR for exploratory laparotomy
CT may be an adjunct for stable patients
Treatment:
Blood product resuscitation
Antibiotics if concern for infected graft/sepsis
NGT/OGT with continuous suctioning
Surgical repair of defective graft and aneurysm repair
Acute Mesenteric Ischemia
Acute occlusion of the mesenteric arterial vasculature, usually from an embolic source or rupture of a plaque
Presentation:
Pain out of proportion to abdominal examination
Risk factors:
Smoking, hypertension, hyperlipidemia, diabetes, cardiac arrhythmias, cardiac valvular disease
Diagnosis:
CT angiography or catheter-based angiography
Treatment:
Anticoagulation
Pain control
Vascular surgery consult to evaluate for thrombectomy/thrombolysis or bypass/stenting
General surgery consult if there is evidence of bowel necrosis requiring resection
Prognosis:
Mesenteric ischemia requiring bowel resection is associated with a 15-fold increase in mortality
Overall mortality for mesenteric ischemia requiring surgical intervention exceeds 50 percent
