Grand Rounds Recap 12.9.20
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Physicians in Leadership and beyond: Curating Your Career Pathway to Success with Visiting Professor Dr. Patsy McNeil (UCEM Class of 2000)
Be Ready:
Be a great emergency medicine physician and a great work colleague
Being flexible
Be financially ready to do what you want to do, rather than what you have to do
Five Factors of Consideration
The Work
Physician income
‘Young person’ specialty
Constantly review how your work fits into the life you want
Recognize that your view of work will evolve over time
Be tactical about what you want, but keep your eyes on work that you find rewarding
The arc of the average EM career ends early
The Family
The spousal effect
Children
Eldercare
Health and Lifestyle
Schedule
Physical Stressors
Emotional and mental stressors
Financial Tolerance
“Don’t work for your house”, don’t work because you have to pay your mortgage
Lifelong Learning
Learn for your current work
Learn for your work future
Learn for yourself
Careers as a Physician Leader
CEO of health system
CMO of health system
CIO of health system
Healthcare business/physician executive
Business partner in healthcare venture
Medical director of emergency department
Medical director of integrated care specialty
Branding
The process of creating a unique name and image, establishing a significant and differentiated presence
What does a leader look like?
“Tall, white, male”, classic board at large corporations
Be the leader you want to be, no matter who you are or what you look like
Leadership Top Five
On stage
Maximize your strengths and improve your weakness
Be genuine
Authenticity
Don’t brown nose
Be observant
Clinically valuable
Recognize allies and enemies
Read the room and read the people
Be impeccable with your word
Don’t break your word
Do the right thing
Make choices that are aligned with your values
Curate relationships with other leaders
You’re gonna need a posse
Make sure at least one of those people will tell you the truth
Surround yourself with people to add to your path
R1 Clinical Treatment: Anaphylaxis WITH Dr. Tony Fabiano and Dr. Jess Koehler
Diagnosis
Acute onset and includes mucocutaneous symptoms and at least one of the following:
Respiratory symptoms
Hypotension
End organ damage due to hypoperfusion
Rapid development of at least two of the following after exposure to known or likely allergen
Skin and mucosal involvement
Respiratory symptoms
Hypotension or associated symptoms
Persistent GI symptoms
Hypotension after exposure to known allergen
Treatment
Epinephrine
Cochrane review did not find any studies that met inclusion criteria (RCT)
We know it is an effective treatment thus we cannot create an ideal study to evaluate epinephrine versus no epinephrine
Agonizes a1, b1, b2 receptors
Increase PVR
Decrease vascular permeability
Increased bronchodilation
Dosage
Max plasma concentration occurs more rapidly with IM admin rather than subcutaneous
Thigh > Deltoid
IV not recommended due to arrythmogenic side effects
Appropriate dosage is unknown
Most guidelines say 0.01 mg/kg for initial dose
Alternatively 0.3-0.5mg
Repeat doses of epinephrine may be indicated if persistently in anaphylaxis
IV crystalloid bolus indicated if concern for circulatory collapse
Antihistamines
No benefit for the life threatening symptoms of anaphylaxis
Small amount of data to support their use for mild allergic reactions
Can help decrease cutaneous manifestations
Side effects not negligible in higher doses
Anticholinergic
Glucocorticoids
Theoretical mechanism of downregulation of late-phase eosinophilic inflammatory response
Data suggests there is no decrease in incidence of biphasic anaphylaxis
Serum tryptase
Theoretical value, it is released during mast cell degranulation
Sensitivity and specificity are too low for it to be clinically useful
Neither peak nor delta correlate with severity
Anaphylaxis shock
Epinephrine infusion to map of 65
May use additional pressors
Consider vaso or phenylephrine if tachycardic
Consider norepinephrine if relatively bradycardic
Consider IV methylene blue if continued refractory to epi
Consider ECMO
Biphasic anaphylaxis
Feared complication of recurrent anaphylaxis from 1-72 hours after initial episode
Rates are likely lower, possibly around 5%
No clear observation time, recommend individualized approach
Anaphylaxis follow-up
Ensure patient has epinephrine auto-injectors
Steroids have not been shown to prevent biphasic anaphylaxis
Return precautions
Allergist follow up
R2 CPC: MIS-C WITH Drs. Kimmel and Baez
Case:
Adolescent aged male with history of asthma and UTD immunizations. Presents with headache, myalgia, fatigue, sore throat, painful oral lesions. Negative strep test at PCP. Negative covid test. Develops fevers and rash on arms which progresses to rest of the body.
Exam is toxic appearing, conjunctival injection, dry mucous membranes with cracked lips, and oral lesions. Bilateral cervical lymphadenopathy, mild neck stiffness, and blanching maculopapular rash on trunks, arms, legs, palms, soles.
Normal WBC count with left shift, thrombocytopenia, creatinine 1.17, transaminitis with direct/indirect elevated bilirubin, elevated ferritin, D-Dimer, PT/INR/fibrinogen.
A test was ordered to make the diagnosis…
Covid Ab IGG - Positive
Diagnosis: MIS-C (Multisystem Inflammatory Syndrome in Children)
Hospital course: Patient admitted to HM. Given IVIG, methylprednisolone, treated empirically with doxycycline. TTE unremarkable. Improves throughout the week. Discharged with follow up.
Definition of MIS-C
Patient under 21 years old presenting with fever, lab evidence of inflammation, and clinically severe illness, multisystem organ involvement
And no plausible alternative diagnosis
And positive for current or recent covid by PCR, serology, or antigen test
Epidemiology
Generally older age range when compared to Kawasakis
Treatment
Without shock or coronary involvement
Low dose ASA, IVIG, steroids
Severe illness
High dose ASA
Consider AC
Consider inotropic support or VA ECMO
Consider biologics
EM + PEM Conference: Critically Ill Pediatric Cases WITH Dr. Patrick Walsh and PEM Faculty and Fellows
Case 1: Shocky pediatric patient with concerning abdominal exam
Pediatric patient who is not responding to stimuli (unfamiliar trauma bay, strangers, IV attempts) should make you more worried
Prioritize access and resuscitation while forming a differential diagnosis
Always consider non-accidental trauma
Does not have to have external signs of injuries
Case 2: Shocky infant in wide complex tachycardia
If monitors are giving trouble, clinically reassess patient
Vitals can be obtained manually without a monitor
Be wary of intubating severely acidotic patients
Patient was hypotensive with a wide complex tachycardia
Cardioversion successful with 0.5-1J/kg
SVT
Typically placed on propranolol or digoxin
Most will resolve with no recurrence off medication by 6-12 months
ALCAPA (Anomalous left coronary artery from pulmonary artery)
Life threatening congenital abnormality
Two variants
Infants <2 years of age
Signs of CHF and dilated cardiomyopathy
EKG with signs of ischemia
Often in anterolateral leads
Q waves in lateral limb leads
Older children >2 years of age
Have more collateral vessels
Often asymptomatic to adulthood
At risk for sudden death
Mitral regurg murmur due to ischemia of papillary muscles
EKG may be normal
