Trouble Abroad - Recap and Commentary

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Trouble Abroad - Recap and Commentary

The responses provided so far have been phenomenal, both insightful and provocative.  I am truly impressed.  As mentioned by several of my colleagues, many of these cases are deeply personal, not only because they involve highly vulnerable populations, but also because they may put clinical providers in harm’s way.  When we begin to discuss ethics, especially global health ethics, there is often no single correct answer to a given scenario.   We often deal with hard science and hard facts but sometimes you just have to go with your gut and do what you think is right.  If you missed the first case and initial discussion, check it out here.

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Grand Rounds Summary - July 22

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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
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Grand Rounds Summary - July 15

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Grand Rounds Summary - July 15

Oral Boards

African Tick Borne Illness

  • Rickettsial illnesses (specifically Africae)
  • Empiric doxycyline & ID consultation for presumed tickborne illnesses
  • Rickettsia africae classically presents 4-7 days post exposure with thromobocytopenia and hyponatremia

Hypothermic cardiac arrest

  • Fixing the temperature is the most critical thing
  • EKG findings of Osborne waves in hypothermia
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Interpretation of Cervical Spine CT's

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Interpretation of Cervical Spine CT's

It's 6pm in the ED on a sunny summer afternoon- you're working as a single coverage physician at a level 3 trauma center.  You are noticing an uptrend in the trauma patients being brought in over the past few hours. While log rolling yet another patient, an EMS provider tells you that they have been making runs nonstop- all of the hospitals downtown are overloaded, and it doesn't look like it will slow down anytime soon. Your modest trauma bay is already full, and you're starting to sweat about the state of the department- there are 4 patients in the pod you haven't even seen yet, 2 with abnormal vital signs.

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Out on a Limb - Moonlighter

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Out on a Limb - Moonlighter

You are a 4th year EM resident moonlighting on your first day in a remote area as the solo provider that has minimal availability to consulting services. The nearest major hospital is approximately 100 miles away.

A 5 year old child enters your ED at 3 am with a large, complex laceration to the face from a dog bite which will likely require sedation and a layered closure.  His injuries were sustained approximately 6 hours ago. The wound is complex and will require a multi-layered closure and there are a couple of areas of tissue avulsion. You have 1 or 2 cases of similar experience from approximately 1 year ago on your plastics rotation...

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Out on a Limb - Troubles Abroad

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Out on a Limb - Troubles Abroad

You are an EM resident from the US working in a rural South African hospital as part of a global health elective.  The political climate is such that a prolonged government strike is leading to severe staffing and resource shortage.  There are no disposable gloves and many procedures are performed barehanded.  One day during rounds in the Labor Ward, the Chair of the department asks you to draw blood from an HIV-positive woman in labor as the team is presenting the patient in her room.  The only remaining gloves in the hospital are a few pairs of sterile gloves reserved for emergency cesarean deliveries.  There are high rates of HIV-exposure and many staff members are currently on post-exposure prophylaxis.

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Out on a Limb - "Is there a Doctor on Board?!"

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Out on a Limb - "Is there a Doctor on Board?!"

You are enjoying a cocktail on the way to Hawaii on a well earned vacation when a voice comes aloud overhead, “Attention all passengers. If there is a doctor or health care provider present, we ask that you please come to the front of the plane immediately.” From your vantage point in the back of the plane, it becomes clear very quickly that no one is volunteering. You find yourself being stared at by a plane full of people as you make your way to the front, to find a morbidly obese Caucasian female with a flight attendant at her side. You start your encounter…

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Grand Rounds Recap - 5/20/15 - Disaster Day!

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Grand Rounds Recap - 5/20/15 - Disaster Day!

Explosive Injury with Dr. Calhoun

Explosive injuries cause high numbers of casualties compared to chemical and biological incidents

Determinants of injury

  1. Type of blast: high vs low explosive (has to do with how rapidly the gas is released)
  2. Environment: close quarters vs open field
  3. Presence of projectiles
  4. Distance from the explosion
  5. Shielding
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Pediatric Abdominal Ultrasound

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Pediatric Abdominal Ultrasound

After a long shift in the adult ED, jam packed with patients presenting with abdominal pain, your looking forward to a brand new day in the Peds ED.  Your first patient, however, gives you PTSD-like flashbacks to the previous days shift.  

Alice is a 8 year old girl who developed abdominal pain last night.  Her parents thought that she would be okay waiting until morning, that the pain would pass in the night.  On waking this morning, however, the pain was still there.

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CT Abdomen and Pelvis - Hollow Viscus

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CT Abdomen and Pelvis - Hollow Viscus

It's weird how you get runs of patients in the ED.  Some days it seems like it's nothing but wall-to-wall low risk chest pain, altered mental status, or back pain.  Today (and a lot of other days), it's abdominal pain.  Scanning the board you see seemingly nothing but Level 3 acuity patients with the chief complain of "Abdominal pain."  Out of the scores of patient's, you seen so far, the last 2 worry you the most:

Andrea is a very pleasant 20 year old student from a local college.  She came in after having symptoms of right lower quadrant pain over the course of the past 8-12 hours.  She didn't recall any migratory symptoms but does endorse a lack of appetite, nauseousness, 2 episodes of vomiting (started after the pain), and steadily worsening pain.

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Grand Rounds Recap - 4/29/15

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Grand Rounds Recap - 4/29/15

Morbidity and Mortality Conference with Dr. Stull

1. Pericardiocentesis tips and tricks

  • Your needle should be at a 45 degree angle when entering the chest at the xyphoid process, aim to the L shoulder/scapula
  • Use a spinal needle and keep the stylet in while entering the skin in order to prevent needle clogging
  • Keep head of bed at 30 degrees to encourage the fluid to drain inferiorly
  • Can attach an EKG lead to the needle by an alligator clip. You will get an ST elevation in that lead if you hit the myocardium
  • Can use an A.line kit to place a catheter into the pericardium for continuous drainage
  • US probe position: subxyphoid
  • How to Video on TamingtheSRU - http://www.tamingthesru.com/blog/acmc/pericardiocentesis
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Grand Rounds Recap - 4/22/15

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Grand Rounds Recap - 4/22/15

Oral Boards Practice Cases

Case 1 - 22 yo F in a "coma" with normal vital signs. Not responding to Narcan and Dextrose. Found in a garage. On exam, she has sluggish and dilated pupils. pH 6.98, pCO2 29, bicarb 2

High concern for toxic alcohol ingestion: consult DPIC and nephrology for dialysis

  • Fomepizole is the antidote for ethylene glycol only
  • Can use ethanol drip to treat both ethylene glycol and methanol
  • Replace folate aggressively and early 
  • Methanol is metabolized to formic acid, if you give folate you can prevent methanol from going down the formic acid pathway
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Grand Rounds Recap - 4/15/15

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Grand Rounds Recap - 4/15/15

Ocular Emergencies with Dr. Titone

Blood supply to the eye is from the Internal Carotid and drainage is through cavernous sinus.  Bony eye septum is an improtant structure that separates the superficial structures from the deeper structures that have direct communications with the brain.

Key historical factors: recent eye procedures, eye drop use, contact lens use, occupational history, UV ligh exposure

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