Grand Rounds Recap 10.9.19

Leadership Curriculum: Finances and Leadership WITH Dr. Pancioli

Leadership and finances go hand-in-hand, and although physicians are by nature placed in leadership positions we often have much to learn about money. As individuals we undergo an unusual arc of experience from many years incurring debt as medical students, to modest salaries while in residency, followed by sudden and dramatic increase in pay when we graduate to attendings. Beyond the individual sphere we must also learn to manage finances for our practices in some cases, but in preparing to go on to positions of leadership at institutional levels where we will be tasked with making decisions involving dollar amounts on the order of multiple millions per year. What are the major points that we should keep in mind if we find ourselves in such a role?

Taking our emergency department as an example, there are numerous sources of revenue that must be considered. There is clinical revenue, which depends highly upon the payor mix of the patient population. County hospitals that see primarily Medicare and Medicaid patients will be reimbursed only a small fraction of what they actually bill, whereas facilities that see privately insured patients will receive a much larger percentage.

How well individual practitioners within a group document for billing and coding has a significant impact on reimbursement, and often emergency physicians are not fully aware of the scope of care that qualifies for “critical care” time spent with patients.

Academic institutions also have research divisions, but even those with the highest levels of federal funding will still only bring in enough money to keep the division afloat and generally, we cannot expect research to be a source of significant revenue. Conversely, endowments are one of the gems of academic medicine. And endowment is a lump sum of money donated by an individual or an organization that is placed into an account that “sheds” a certain percentage of the total amount per year. Theoretically this could go on indefinitely, and departments that have such endowments can use them to guarantee funding for projects and initiatives that fulfill their noble but non revenue generating missions.

When negotiating for contracts we should keep several key points in mind. First, understand that sometimes certain things are not negotiable, an example could be starting packages for new graduates. Secondly, the money should be the last part of the discussion after settling out the details of clinical time, titles and roles, office space, research needs, and other intangibles. Lastly, if you bring something to the table, expect something in return. In other words, if you have expertise within a particular niche you should ask for signing bonuses, higher salary, buydown on clinical time for research, and other necessaries like equipment. Involving others and what they need as well will raise the mission of the whole department

R4 Case Follow Up: Cardiac Tamponade WITH Dr. Klaszky

Cardiac tamponade is a potentially lethal complication of pericardial effusion that must be considered in patients presenting with chest pain. The physiology of tamponade depends on the rapidity of fluid accumulation rather than the absolute volume as moderate sized effusions that accumulate quickly can have a much more pronounced effect than those that grow over a much longer period of time.

How do we diagnose cardiac tamponade? Beck’s triad is the classic constellation of physical exam findings, but is very seldom present in reality. The first element, muffled heart tones, is seen in only 28% of cases. Hypotension is found in only 26%, and JVD is exceptionally rare at only 7%.

What about diagnostics testing? Low voltage EKGs are somewhat more sensitive at about 42%, and while electrical alternans is slightly more specific it is still highly insensitive. However, where our physical exam and EKG are woefully underperforming, chest xr-ay gives us some hope. New cardiomegaly on chest xray is reported up to 89% sensitive for pericardial effusion, so if you have a young person with chest pain and a newly enlarged heart on their xray you should be much more suspicious. In this case you should definitely place an ultrasound probe on your patient’s chest to look for effusion and tamponade.

What are the sonographic findings of tamponade? Right atrial systolic collapse is the earliest sign and occurs even before hypotension. If you see RA collapse then you should either be calling interventional cardiology or cardiothoracic surgery if you’re in a hospital where you have them available, or calling for transport to an appropriate referral center. Right ventricular diastolic collapse occurs somewhat later and may be difficult to detect if the patient is markedly tachycardic. If that is the case then you can use M-mode on the ultrasound machine to measure RV size during systole and diastole to determine if there is diastolic collapse. A plethoric IVC is not a very specific finding, but if interpreted in context with other signs can add to your overall picture.

Another method of assessing for tamponade physiology is to measure mitral and tricuspid valve inflow velocities. While this may sound daunting it actually is not that difficult provided that you can obtain adequate views. MV/TV inflow velocities can be thought of as analogous to the phenomenon of pulsus paradoxus. This is the state in which the shifting pressures within the thoracic cavity produce wider than normal variations in systolic blood pressure greater than 10mmHg. Greater than 25% difference in velocity across the mitral valve, or 40% across the tricuspid, are diagnostic.

Management can either be temporizing or definitive. In the former case you should give fluid boluses in order to optimize preload, but if your patient remains hypotensive then use vasopressors judiciously and with the understanding that they may not produce the desired effect. The physiology does not involve a problem with the myocardium itself and so pressors and inotropes will not address the underlying problem.

Definitive management is either by pericardiocentesis or pericardial window. Pericardiocentesis is useful for the drainage of free-flowing, circumferential effusions. Ultrasound can be used to identify the area of greatest effusion volume (subxiphoid, apical, or parasternal), and can also be used as dynamic guidance for steering the needle. If you expect that the patient may need repeat drainage then you can consider placing a triple-lumen central line over a wire using the standard Seldinger technique. Pericardial windows are useful when the effusion is more likely to be purulent, loculated, or otherwise unlikely to drain, and need to be performed by a surgeon.

Lecture Series: The Great Debate - Chemical vs Electrical Cardioversion for Stable, New-onset Atrial Fibrillation WITH Drs. Baez and Continenza

Opening Statements

Baez: Atrial fibrillation is common and there is proven decrease in morbidity and mortality when normal sinus rhythm can be done within 48 hours of onset. Despite this, there are no clear guidelines on which method to use and there is fairly wide variance in preference across the country. For the purposes of this debate, I take the stance advocating for chemical cardioversion. Although it has been shown to have a lower overall success rate of 50% vs the 90% success rate of electrical cardioversion, it carries several benefits. These include less pain, none of the risks involved with sedation required for electrical cardioversion, and much lower risk for lethal arrhythmias and burns.

Continenza: For the purposes of this debate I will take the stance of advocating for electrical cardioversion. This is for the incontrovertible reasons that it works, it’s faster, and patients have been shown to prefer it over chemical cardioversion.

What specific approach do you recommend for stable, new-onset atrial fibrillation?

Baez: There are many medications that one could choose, but of them all procainamide is the most widely used and safest from a side-effect profile standpoint. As a class 1a antiarrhythmic it blocks the flow of sodium ions across cell membranes and slows conduction across the AV node while also increasing the refractory period of the cell. It is given in 10-15mg/kg doses up to a max dose of 1g over 20-30 minutes and shows a conversion rate of about 50% in multiple studies. If successful, you can expect conversion in the vast majority of patients within about two hours of giving the medication. Side effects of procainamide include ventricular arrhythmias and hypotension, but these can be counteracted by close monitoring and fluids. Procainamide is contraindicated in myasthenia gravis, congestive heart failure, and renal failure.

Continenza: Several different approaches to electrical cardioversion have been studied, including an escalating 100-150-200J protocol and three attempts with 200J. Overall the triple-200 approach seems to work better, especially in patients with BMI > 25, but if your patient is small then you can consider the escalating method instead. Regarding pad placement, there has still not been a conclusive study to show that AP positioning is better than anterior/lateral. Discussions about sedation are beyond the scope of this debate, but as general rules you should be considering potential airway problems, utilizing checklists to minimize errors, and communicate with your nurses to avoid errors like shocking without sedating.

Which method has a shorter length of stay overall?

Continenza: Electrical cardioversion is faster. Studies have shown that the median length of stay in the ED after electricity is 3.5 hours vs 5.1 hours for chemical.

Baez: I’m skeptical of those figures for several reasons. Sedation takes time to set up and recover from, and operationally our own ED protocol mandates a period of observation after electrical cardioversion. Practically speaking, I would recommend starting your pharmacologic agent while you obtain consent and get set up for sedation. Your patient may convert while you are getting all of that together.

What about patients with structural heart disease and CHF?

Drs. Baez and Continenza agree in these cases that it should come down to a risks vs benefits discussion with the patient and their family.

What about cost?

Baez: There’s actually not much data, but what is available suggests that pharmacologic methods may be cheaper. A vial of procainamide costs about $97, but with electrical cardioversion there are lots of incidental costs like equipment, extra personnel for sedation, and the extra time.

Continenza: Electricity is more effective, therefore more likely that you will be able to discharge the patient and thus save all of the associated costs of admission to the hospital.

Which method is safer overall, or has less adverse events?

Drs. Baez and Continenza agree that both methods appear equivalent in their rates of adverse events, but that patient selection is key to minimizing risks.

Our audience was asked to vote on which method they preferred prior to the debate and then once again afterwards to gauge if their minds had been changed. The vote from before the debate came out at 59% favoring electricity, and 64% afterwards. It seems that in this debate Dr. Continenza was able to make a convincing argument and move the needle ever so slightly further in favor of electrical cardioversion.

Pediatrics: Hypoxia WITH Dr. Michael Stratton

There are several important systems that can be compromised to produce hypoxia in pediatric emergency medicine. The vast majority of cases are due to primary lung pathology, but CNS depression, cardiovascular shunts, and upper airway obstruction are also on the differential diagnosis.

In case 1 we discussed a 6 month old with a ductal dependent lesion. Important learning points were to remember to obtain pre-ductal blood pressure and oxygen saturation on the right arm; keep in mind that supplemental oxygen may worsen these patients by dilating pulmonary vasculature and thereby worsening systemic hypotension; give small fluid boluses of 5ml/kg; treat pharmacologically with prostaglandins and consider furosemide if your patient is obviously volume-overloaded.

In case 2 we discussed a 7 month old with bronchiolitis. Key learning points were to remember to educate parents on devices and techniques for proper suctioning; give supplemental oxygen via nasal cannula or high-flow nasal cannula to reduce work of breathing; avoid continuous pulse-oximetry if your patient’s initial oxygen saturation is adequate to avoid unnecessary testing or admission due to transient desaturations; and there is still no data to support albuterol or bilevel positive-pressure ventilation for bronchiolitis.

In case 3 we discussed a case of upper airway obstruction secondary to severe croup. Major learning points were that the combination of stridor and hypoxia should be cause for alarm; administer supplemental oxygen, give steroids and racemic epinephrine, and call for airway backup if none of that is working. Trans-tracheal jet ventilation can help oxygenate is a substitute for cricothyrotomy in children younger than 10 (although the age continues to decrease with some sources now saying 8), but will not help you ventilate. It may buy you enough time with oxygenation to perform a more controlled intubation from above.