Grand Rounds Recap 10.12.22
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Leadership Academy- Advocacy in leadership WITH Dr. Yates and Dr. Jarrell
Step 1: Define Advocacy
Definition of advocacy: “the act or process of supporting a cause or proposal”
ACEP Code of Ethics for Emergency Physicians: “Principles for Ethics of Emergency Physicians #10: Emergency physicians shall support societal efforts to improve public health and safety, reduce the effects of injury and illness, and secure access to emergency and other basic health care for all.”
Levels of advocacy: personal, individual/patient level, departmental/institutional, governmental
Step 2: Identifying Stakeholders
Pillars of support (stakeholders) are institutions or sections of a power structure that are required in order to maintain the status quo
Identifying stakeholders:
Understand power structure within each pillar
Leadership team? Department? Single person?
Who is the spokesperson? Who makes the decisions?
What are the resources each stakeholder has that will help or hinder your goal?
Authority, human resources, skills and knowledge, materials, sanctions/punishments
Step 3: Spectrum of Allies
After determining key stakeholders in the arena that you are advocating, next you’ll need to determine the players within these pillars that are supportive, opposed, or neutral to your cause
Supportive: active vs passive
Neutral
Opposed: biggest area to build relationships, determine concerns, find compromises
Step 4: Personal Narrative
Define goals
How does your personal narrative and story convey these values and strategy?
Action item
What solution are you proposing? What does your audience need to understand about the next step?
Audience
Who is your audience? Will they relate to your story?
Purpose
What key element in your advocacy will come across better in a narrative compared to facts?
What constitutes a narrative?
Character, plot, action or choice, outcome
Questions to answer: Why do I care? Why now? Why should we care?
Pitfalls in narrative: jargon, individualized stories without broader community context, too much date, distracting story details
Step 5: Targeting your message
How you message depends on shared values
Strategies to reach your audience: one-on-one meetings, phone calls or emails, petitions, rallies, traditional media, social media
Compromise and “Failure”
Compromising: understand what you are willing to settle on
Failure
Where was your strongest opposition?
What were the biggest sticking points?
What groups surprised you? What groups may you be able to convince with a different story of data?
How do you respond?
Political Advocacy
Personal vs Professional
Advocacy groups to engage with:
Medical organizations- ACEP, AMA, state or county medical associations
Community organizations
Hospital government relations office
R3 Taming the SRU WITH Dr. Finney
Case: Middle aged male who presented to the ED with palpitation and SOB. Patient was found to be in atrial fibrillation with RVR that was later unstable, complicated alcohol withdrawal, possible new onset heart failure, and respiratory failure.
Etomidate
Etomidate Advantages
Fast acting
Short duration of action
Allows good muscle relaxation for orthopedic procedures
Hemodynamic stability
Etomidate Disadvantages
Rapid elimination makes it suboptimal for longer procedures
No intrinsic analgesia
Higher doses can lead to adrenocortical suppression but has not been shown to be consequential
Myoclonus observed in up to 20% of ED patients but this rarely causes procedure failure or delay
Post-procedure emesis
Energy used for cardioversion
There have been varying studies for energy used in cardioversion with escalating energy (100J, 150J, 200J, 200J) and non-escalating energy protocol (200J shocks only)
Can start with 100J and escalate or just start at 200J
Anticoagulation after cardioversion
2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:
Class I Recommendation: “For patients with AF or atrial flutter of 48 hours’ duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended for at least 3 weeks before and at least 4 weeks after cardioversion, regardless of the CHADSVASC score or method (electrical or pharmacological) used to restore sinus rhythm.”
Ketamine-facilitated Intubation: using dissociative dose ketamine and atomized lidocaine for intubation over RSI method
Benefits:
Dissociation provides amnesia and analgesia while maintaining airway tone and respiratory drive
Can be used in uncooperative patients
Main concerns
Patient may bite down on laryngoscope and ETT
Increased airway tone can make laryngoscopy more challenging
Patient may gag, cough, and adduct vocal cords during intubation which can render ETT advancement more challenging
r4 case follow-up WITH Dr. Chuko
“Failure”
Important to recognize “failure” does occur, especially in medicine
Learn from these instances
Fixed vs growth mindset
Combating blindspots
Use aids without guilt
Use “when-then” and “if-then” thinking
Diagnostician
Not always possible to make a “diagnosis” in the ED
Important to recognize the ED does have diagnostic and therapeutic momentum
pediatric simulation: status asthmaticus WITH Cincinnati pem
Status asthmaticus: A prolonged and severe asthma attack that does not respond to standard treatment (bronchodilators and steroids)
Respiratory failure: inability to compensate resulting in hypoxia, hypercarbia or both; can be clinically defined as need for positive pressure to maintain oxygen levels >90% or pCO2 levels < 50
Respiratory failure is a syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, it may be classified as either hypoxemic or hypercapnic.
Hypoxemic respiratory failure (type I) is characterized by an arterial oxygen tension (Pa O2) lower than 60 mm Hg with a normal or low arterial carbon dioxide tension (Pa CO2). This is the most common form of respiratory failure.
Hypercapnic respiratory failure (type II) is characterized by a PaCO2 higher than 50 mm Hg. Hypoxemia is common in patients with hypercapnic respiratory failure who are breathing room air.
Note: these levels are based on arterial blood gas sampling, so if I-stat or gas obtained as venous or capillary that must be taken into account
Aggressive medical management including:
o IM epinephrine and/or IV terbutaline
Order Epi-Pen Jr (0.15 mg of epi) for patient weighing 10-25 kg (this is per the Kemp and Sicherer articles; dosing in Lexi-comp)
Order Epi-Pen (0.3 mg of epi) for patients weighing 25 kg or more
In kids <10 kg, use the 1:10,000 concentration IM as described in the code book (for dilution reasons)
IM, not SQ – evidence supports more rapid absorption and higher plasma levels of epi when administered IM in thigh compared to SQ or IM in arm
o IV methylprednisolone rather than prednisone/dexamethasone
o NS fluid resuscitation: For current or anticipated hypotension from magnesium, albuterol, dehydration, or increased intrathoracic pressure from obstructive process, etc.
Goal: increase preload
o Non-invasive positive pressure ventilation (NIPPV)
In conscious patient able to protect airway
Reduces WOB and energy expenditure
o Albuterol setup in patient getting NIPPV
Can provide CPAP with Mapleson bag as patient breathes spontaneously while continuous albuterol is administered via T-piece
Similar setup works for BMV, however if patient is reclined into supine position the bag – t-piece – mask setup needs to be reorganized to prevent spillage of medication into the mouth and nose; this is the one time the green bag is physically removed from the 90-degree angle in the BVM setup
Risks of intubation in status asthmaticus
o Transition from negative to positive pressure ventilation increased intrathoracic pressure→decreased preload→asystole
o How to prepare for this intubation if you feel you have to: ICU consult/PICU-ED team, start epi drip prior to intubation, have backboard down and code dose epi. ketamine would be ideal sedative due to bronchodilatory effects but etomidate is appropriate; succinylcholine or rocuronium appropriate for muscular blockage.
o In this scenario the patient would be an ECMO candidate if arrested during intubation, know where ECMO can be started and on whom at your facility
o Indications for intubation in a severe asthma exacerbation:
cardiac arrest
respiratory arrest or profound bradypnea
physical exhaustion, such that NIPPV is ineffective
altered sensorium, such as lethargy or agitation, interfering with oxygen delivery or anti-asthma therapyText
