Grand Rounds Summary - July 22

Dr. Miller - Leadership Curriculum

"Give me six hours to chop down a tree and I will spend the first four sharpening the axe" - Abraham Lincoln

In order to lead the team, you need a reflection of what you need to improve as a leader:

  • In a survey of academic chairs, communication, decision making, collaboration and trustworthiness were the top rated characteristics
  • In a survey of UC EM residents and faculty confirmed that these apply to every level of training

We did a thought through a small group exercise by year and the specific leadership qualities emphasized in each year: 

  • R1 year - Problem solving while building rapport - R1 leadership comes from respect developed from being humble, building social capital and promoting a team approach (unique leader values from R1 survey: Open to new ideas, good listening, self-control)
  • R2 year - Communication is key - utilizing resources available, being pragmatic and anticipating challenges. Calmness during stress garners respect in the SRU, in the helicopter and in the pod (unique leader values from R2 survey: problem solver, mediation, consistency)
  • R3 year - Adaptability - staying consistent while knowing how to create a positive interaction when dealing with different populations, whether your patients, their families or your trauma surgeons needs stabilization (unique leader values from R3 survey: decision making, collaboration)
  • R4 year - Taking a step back - keeping the big picture in mind empowers your staff to own their patients and keeps the karma of the pod positive and making yourself available and approachable (unique leader values from R4 survey: self control, pragmatism)

Drs. McDonough, stettler and Miller - How to Give Bad News

In the ED we need to go from stranger to telling someone they have cancer in 10 minutes, it's important to know where they are starting from before you tell them what you know

VFib arrest case

  • Give true time / empathy - pass off your phones and dedicate time to the conversation
  • Prepare the patient for bad news but don't hedge on using the word 'death' early in the conversation
  • Identify who is in the room and who you should be primarily addressing

New cancer case

  • When you are uncertain - convey that to families but also convey the seriousness of the conversation
  • Pictures can help solidify and resonate with patients and families of the severity

Procedural complication

  • Be direct and take ownership about what happened without using medical jargon
  • Your consent needs to be appropriate, full and set the stage if that second conversation needs to happen
  • Apologies do not imply guilt

Drug Overdose Family Discussion after ROSC

  •  Redirect families to the patient's current clinical course rather than the etiology that is suspected but unknown
  • Post-ROSC prognostication is very poor in providers in first 72 hours post-ROSC

Dr. Boyer - Taming the SRU Case Followup

Hypotensive LVAD Patient

  • LVADs can be temporizing, transition to transplant or destination therapy
  • Get your LVAD team involved early
  • Auscultate for mechanical whirr
  • Obtain BP with manual doppler MAP (goal 70-90) as pulse pressure is minimal.

Complication 1: Pump thrombosis

  • Evidence of RBC lysis (jaundice, elevated LDH)
  • Elevated wattage (>2W above baseline or >10W)
  • Start a heparin gtt, consider thrombolytics if life threatening (with your CV surgeon on board)

Complication 2: Suction Event

  • Left ventricular collapse leading to decreased inflow into the LV, may be seen with parasternal long view of cardiac US
  • RV failure
  • Acute arrhythmias
  • Consider a fluid bolus trial and look for bleeding for possible anticoagulant reversal

Complication 3: Drive Line Infection

  • Tunneled connection between batteries and LVAD
  • Often drug resistant infections (pseudomonas, staph and enterococcus most common)

Dr. Polsinelli - Case Followup - Cerebellar Infarct

Etiologies: Cardioembolic, Dissection, Thromboembolic

Physical Exam: Vertigo, headache (more common in younger), nystagmus, N/V, gait disturbance, tuncal or peripheral ataxia

Imaging: CT 26% sensitive, MRI with 20% false negatives in first 24h

Complications: Edema leading to 4th ventricular compression and hydrocephalus (most common 3 days after stroke)

HiNTS exam

  • Head Impulse Testing
  • Nystagmus
  • Test of Skew

Limited data of use by ED providers as the confirmatory study was done by neuro-ophthalmologists - but a nice adjunct to enhance your neurological examination of the posterior fossa.