Pediatric Orthopedics WITH DR. MEHLMAN
Challenges in the Emergency Department with Pediatric Orthopedics
Ace Wraps can cause re-perfusion injury, so use sparingly
With such variation in extremity size, a study found pediatric splints are improperly positioned as high as 59% of the time
Hare Traction splints are too large to effectively use on children
Only 27% of MD students consider their musculoskeletal curriculum adequate
In pediatrics, the number one cause of law-suits was due to fracture
Pinckley Lesion and Seymour Fracture
A 5y patient presents after twisting his finger during a fall. A small drop of blood is visualized proximal to the nail.
This is an occult open fracture just proximal to the nail of the distal phalanx of either finger or toe
It deserves reduction if displaced and sometimes pinning, but always antibiotics
Posterior Hip Dislocation
A 12 yo M fell after football. He was found to be have a hip dislocation after transfer, initially missed on ED review of films.
AVN is in 12% of hip dislocations, 20 times higher risk when reduction >6 hours
Requires immediate reduction prior to transfer
Femoral Neck Fracture
9 yo F playing soccer who fell down. Femoral neck fracture appeared on films. With hypotension, a T-pod was placed.
No indication for T-pod or other pelvic binding in absence of pelvic ring fracture.
Posterior knee dislocation
15 yo M playing football was struck in his right knee. Posterior knee dislocation seen on films.
5-64% rate of vascular injury from this. They routinely require transfer for neurovascular monitoring or intervention
Supracondylar Humerus Fracture
5 yo M fell onto left arm. He was found to have supracondylar humerus fracture. Child had high median nerve palsy (flexor digitorum superficialis loss).
High median nerve palsy (inability to move FDS fully to do “OK” sign) should raise suspicion for a silent compartment syndrome and deserves immediate transfer for monitoring
Pucker sign (area of tissue retraction in the AC fossa) associated with neurovascular injury and pulselessness, indicative of a higher energy injury
Soupy pins after reduction are signs of septic arthritis in supracondylar fracture until proven otherwise.
5 yo F presents after fall on his arm. Olecranon fracture noticed on initial x-ray. Missed Monteggia fracture with radio-capitellar dislocation.
Radius should point directly at the capitellum though the range of motion in AP and lateral views.
Initially missed dislocation will need operative repair due to difficult reduction.
Leadership Curriculum- Recruitment and Team Building WITH DR. STETTLER, FERMANN, and MCDONOUGH
Recruitment starts with identifying qualities that you are trying to recruit
Know your mission
Work with your existing team to understand who will help you deliver this mission
Figure out what speaks to people to recruit them
Philosophies of recruiting
Diversity helps build strength in the department
Not only diversity of age, sex, gender, race, but also diversity of thought, skills
People want to be able to able to envision themselves in the organization
People want an organization that will invest in them
Institutional pride should be present, but understated
You are a senior resident who is working on a research project. However, you have accepted another administrative role and would like to recruit another resident to help complete this research project.
Two methods: sending out to an entire group and soliciting interest, or personally seeking out individuals
Sending out to the entire group allows equal opportunity, self-selects interested individuals, but does not allow you to select your exact partner
Personally seeking out individuals allows you to pick a teammate personally, but may lead to resentment for those who aren’t given the opportunities, and makes the assumption YOU are the best person to select your partners
Building a Team
To build an effective team, you must know your mission, define roles, empower success, and provide feedback
Know Your Mission
To know your purpose, you must know your goals
Define roles, with flexibility
Allow your team to grow personally and innovate
Provide honest feedback, both positive and constructive continuously
Listen and consider
This is your primary role as a leader
Have your team-members provide feedback in order to identify problems early, and provide solutions
Case: You are a resident leader who is part of a small group of residents tasked with re-designing flow and process of resident graduation. You are having a tough time deciding the details. How do you bring a team together to craft solutions?
Consider the number of individuals needed in the group. Too few limits diversity of opinion, too many impedes progress.
Consider creating subcommittees for separate missions to maximize efficiency.
Setting goals and metrics by which to measure achieving those goals will allow more productivity in meetings
Opioid Overdose Prevention Programs WITH DR. JARRELL
Public Health and Social Emergency Medicine
Emergency medicine is uniquely positioned as a specialty to conduct surveillance and research on population health needs
Public Health and Social EM Group is forming to help facilitate communication, collaboration, and career development in this area as well as provide content to all residents on this focus area
Community Opioid Overdose Prevention Programs (OOPPS)
Overdose deaths doubled from 2010 to 2016
Community Opioid Overdose Prevention Programs distributing Narcan can save lives
In a meta-analysis of 11 studies, 100% of patients’ overdoses survived, and 2 studies showed a correlation of OOPPs with lower death rates
Bystanders respond correctly more frequently correctly (moving to naloxone administration) in communities with OOPPS
Narcan Distribution Collaborative
This is a local partnership between social service agencies, and hospital systems to saturate the community in naloxone in Cincinnati
We have handed out 8k doses in the community, but only ~200 are from the ED
34% of people who collected narcan did so in case they overdose, 28% want to use it on family/friends, 46% want to use it if they see somebody who overdoses
Opioid Use Disorder Epic Tool
Referrals to Addiction Sciences have nearly tripled since implementation at UCMC
The total number of patients engaged in treatment has not significantly increased
The number one barrier to this is 71% of patients can’t be reached
Ensure you are telling patients about the referral, and they have given their correct phone number
Hernias WITH DR. LEECH
Inguinal hernia- Most common type of hernia, hernia through the inguinal canal
Femoral Hernia- Hernia below the inguinal canal
Incisional hernia- Can be through linea alba or previous weakened surgical closures of the abdomen
Umbilical hernia- Hernia through the weakness in the site of passage of the umbilical cord
Hiatal- Hernia of the stomach sliding up through the diaphragmatic wall into the thorax
Status of Hernia
Soft, easy to push in
Bowel is stuck through the hernia defect, difficult to reduce, but not ischemic or infarcted bowel
Contents are soft, may hear bowel sounds, no overlying bruising
Bowel ischemic or infarcted
Toxic appearing, tense hernia, overlying bruising and erythema
Examine both standing and lying as it may make more apparent
Assess fascial defect
Look for overlying skin changes which will help differentiate between incarcerated vs strangulated
KUB not sufficient to rule out SBO
Ultrasound can help quantify the size of the fascial defect and see contents, however limited in assessing flow
CT scan is the standard of care for detecting SBO
Definitive treatment is surgical repair
Reducible- elective repair
Incarcerated- 1-2 attempts by ED, then consider consultation of ACS, if successfully reduced - elective repair and return precautions
Strangulated and/or bowel obstruction- Surgical repair
Wellness Curriculum WITH DR. JARRELL AND DR. BANNING
What we are doing well
We have a family in our department
We emphasize a shared mission
We have good relationships with our coworkers
Things We Continually Improve
Planning activities for the sake of wellness sometimes ignores the more systemic problems causing people to be unwell
Wellness activities that make you well both at work and outside it. By emphasizing what you find meaningful in both of those realms, is a very personal thing but what we intend to support as a program
Wellness must be an active and intentional process by the individual
Intentional and progressive integration of wellness inside and outside of work is what causes change