Grand Rounds Recap 2.15.23
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EMS Grand Rounds WITH Dr. ConnelLy
What I learned in my time with Sydney HEMS
The area of NSW is nearly twice the size of Ohio
Staffing model
Rotor wing
Fixed wing
Clinical Capabilitis
Limb Escaratomies
Peripheral nerve blocks
FIberoptic intubations
Craniotomies
Clamshell thoracotomy
On-Boarding
All staff go through a 2 week onboarding training induction
2 months before hand there are hours of videos, SOPs
High fidelity simulations to reinforce learning done before arrival
Learning
Lesson 1
Assess and optimize yourself, your team, your environment, and your patient.
This is the Zero Point Survey - referring to the zero point or time zero on the mission clock.
Often we think of patient care as starting with a primary survey.
The idea with the zero point survey is that you do it *before* your primary survey and it provides a framework for consciously optimizing the non-clinical or non-technical aspects of a mission.
STEP-UP
Self
Physical and Psycological
IM-SAFE
Illness
Medications
Stress
Alcohol
Fatigue
Eating
Psychological
Cognitive Threat/Challenge appraisal: PERCEIVED demands vs. resources
Threat appraisal - stress levels excessive, performance impaired – vapor lock (autonomic arousal, tunnel vision, auditory exclusion, loss of time awareness, impaired memory recall and decision making)
Challenge appraisal - stress levels optimally matched to task, performance enhanced – flow state
External locus of control vs. internal locus of control
Tools
Beat the Stress Fool
Breathe - tactical “box” breathing, control your physiology
Talk - positive self talk - reframing a situation to focus on a positive outcome
See - visualize the procedure or resuscitation
Focus - code phrase or ritual to center yourself e.g. basketball free throw (“Cutting skin” before a cric, “This is what we train for” “I am the best possible person to care for this patient.”)
Team
Environment
Own the Resuscitative Real Estate
Set up how you want the resuscitation to go
Organize your space in the way that will wrok best for you and the patient
Patient
Special circumstances
Peds
Pregnant
Mechanical circulatory support
Update
Partner
Priorities
Clear and well defined
Lesson 2
Lead with kindness
Being liked is a powerful tool of persuasion
We also want prehospital teams or other hospitals to call us back for the next patient
Tricks
Be nice
Ask pointed questions that lead to the answers you want
Embed Presuppositions
Example
Do you want your team or my team to set up for intubation
This does not ask if the patient should be intubated but instead assumes this as fact
Ask for help
Use the group
Push a different button is not getting the results you would like
Be Authoritative
CUSS framework
Concerned
Uncomfertable
Safety issue
Stop
Lesson 3
Actively direct mission workflow. Perform an early primary assessment, prioritize meaningful interventions, and build momentum to destination.
Lesson 4
Leadership and individual priorities (i.e. task focus vs. situational awareness) are fluid. Communication is essential.
Gazelle - constant state of hyper vigilance and broad situational awareness (every sound = omg it’s a lion!)
Cheetah - hyperfocused on goal - catch lunch! - but might miss things like the poacher taking aim
In our world
Pilot eyes in - eyes out
Our pilots provide a great example of this
During normal ops, they’re looking out, scanning the horizon, watching for obstacles, and maintaining broad situational awareness
Sometimes, they need to enter coordinates into the GPS or look at something on their iPad or whatever – they switch to task focus
pilot and the nurse sitting up front switch from Situational Awarness to task focus, they clearly announce it, “My eyes are in.” the nurse will answer something like, “I’m eyes out.”
there’s closed loop communication around the pilot’s shift in attention to ensure someone up front is maintaining situational awareness so that we don’t fly into a cell tower, or a bird, or another helicopter.
using a “standard lexicon,” meaning there’s an agreed-upon and mutually-understood set of terms they’re using to communicate.
Sydney makes this explicit “Eyes on / Eyes off patient” - closed loop communication
Lesson 5
Choose deliberate pause points and share your mental model with your team.
A pause to assess in the beginning
A pause before leaving to check everything is stable, accounted for, and plan going forward is agreed upon
Lesson 6
Everyone brings different skill sets to a call. Make smart and deliberate choices when delegating tasks.
Lesson 7
Add value by prioritizing meaningful interventions – those that are time-critical, preserve life/limb/sight, or impact clinical course.
Prioritize tasks that are time critical
Do the diagnostics or procedures that ensure the patient resieves the most timely care possible
Lesson 8
Cognitively offload in stressful situations. The importance of checklist use increases with the urgency of airway intervention.
There’s a temptation to skip the checklist when there’s an urgent need to act – but using the checklist is actually MORE important when you’re under high cognitive load.
Lesson 9
Decide to do the high-stress procedures now so you won’t hesitate in the moment.
Have the confidence and belief in yourself to do the right thing for your patient, and to do it in a meaningful timeframe and without hesitation.
Make the commitment now – know how to do the procedures (mentally rehearse them) and know what your line in the sand is, then COMMIT.
Lesson 10
Details matter and marginal gains accumulate.
doing the little things right, with the understanding that small gains are additive, and that details can be the difference between a good outcome and a poor one.
Lesson 11
Find what you love to do and surround yourself with people who make you better at doing it.
R4 Case Follow up WITH Dr. Broadstock
Case
Young male patient presenting with weakness for 2 weeks. Intermittent fevers, chills and body aches
Chest pain, shortness of breath and some hemoptysis
Found to have a significant AKI, Hyperkalemia, Leukocytosis, elevated Transaminases, low retic count, urinalsyis with 69 WBCs
Postive HIV test
CK 9000
Interventions
HyperK treated, Antibiotics and imaging
Imaging showed Pneumomediastinum
Postive HIV Testing
HIV RNA Day 10-33
P24 Antigen +7 Days
HIV 1 or 2 Antibodies +12 days
We test for P24 and antibodies for HIV 1 or 2
This patient had an active acute HIV infection without seroconversion
Diagnosis
HIV myositis
HD for his acute rhabdomyolysis
Anemia leading to transfusions
Discharged to IPR
Acute HIV Infection
Acute, self-limited viral infection, including fever, fatigue, sore throat, pharyngitis, lymphadenopathy, muscle aches, diarrhea, and a rash (often maculopapular). They can occur within a few days of exposure or up to 6 weeks after, and usually last about 14 days. Can cause transient drop in CD4 count (like in our patient) which can lead to opportunistic infection. No antibodies have been produced, so viral loads are usually very high and patients transmit the infection disproportionately at this stage.
HIV Myositis
Multiple forms of myositis can occur with HIV infection. Polymyositis, infectious pyomyositis (usually GAS, can be salmonella or sometimes toxoplasma), inclusion body myositis have all been described. Polymyositis is not typically associated with significant immunosuppression and might occur at any stage during the course of the disease. Typically, polymyositis presents with a subacute, progressive, proximal muscle weakness associated with an elevated creatine kinase level. The cause remains unknown. Some nucleoside reverse transcriptase inhibitors, notably azidothymidine, are known to cause myositis as a side effect.
HIV related renal disease
HIV Associated Nephropathy (HIVAN)
Form of FSGS
Renal recovery can occur with ART
Can occur prior to HIV seroconversion
HIV Immune Complex Kidney Disease
Less common than HIVAN
Develops later in disease course
Better prognosis
Dermatologic Manigfestations of HIV
HIV Associated
Facial molluscum in an adult
Proximal subungual onychomycosis
Herpes zoster scarring
Oral hairy leukoplakia
Bacillary angiomatosis
Widespread dermatophytosis
Severe seborrheic dermatitis
AIDS defining
Chronic herpes simplex virus ulcers
Extrapulmonary tuberculosis
Kaposi sarcoma
Extrapulmonary cryptococcosis
Disseminated mycosis
Atypical disseminated leishmaniasis
Disseminated non-TB mycobacterial infection
R1 Clinical Knowledge: Vitamin Deficiencies WITH Dr. de Castro
Vitamin Deficiency
Water Soluble
Exctred in the urine, common to have deficiencies, less common toxicity
Fat Soluble
Stored in fat or liver, uncommon to have deficiencies, more common to have toxicities and can have deficiencies if there is fat malabsorption
Conditions that can lead to malabsorption
Infections
HIV
Parasites
Tropical sprue
Whipples disease
GI
IBD
Crohn’s
Short Bowel Syndrome
Gastric Bypass
Chronic Diarrhea
Biliary Obstruction
Systemic
Infiltrative disease like amyloidosis
Cystic fibrosis
Kidney disease
Liver disease
Pernicious anemia
Other
ETOH use
Anorexia
Diet
Vitamin A
Function
Assists in corneal and conjunctival development
Helps with the processing of light perception
Deficiency:
Night blindness (nyctalopia)
Dry, scaly skin
Xerophthalmia - spectrum of eye disease characterized by pathologic dryness of conjunctiva and cornea manifested by Bitot spots (keratin debris)
Corneal degeneration and erosion (keratomalacia) → scarring and blindness
Sources - eggs, sweet potato, green leafy vegetables, yellow/orange veggies with carotene like carrots, tomatoes, cantaloupes, bell peppers
Rarely seen in the US or resource-rich countries
Prevalence of vitamin A deficiency is approximately 30% among children under age 5 worldwide and nearly 50% in young children in South Asia and sub-Saharan Africa
World’s leading preventable cause of childhood blindness
Vitamin D
Function
Calcium homeostasis
By promoting calcium absorption, bone resorption, and maintaining calcium and phosphate levels
Important in bone remodeling
Deficiency
Can be seen in people who have inadequate exposure to sunlight
Rickets in children cause growth impairment and long bone deformities
Osteomalacia in children and adults, which is a bone-thinning disorder
Osteoporosis, Bone pain and tenderness, muscle weakness, fracture, and difficulty walking
Symptoms of hypocalcemia include Muscle aches, weakness, and twitching
Mood disorders and depression
Sources
Very few foods naturally contain Vitamin D, major source is through synthesis in the skin that is dependent upon sun exposure
Can also be found in fortified foods such as cereals and supplemented in milk
Vitamin E
Function
Protects RBCs and membranes from free radical damage
Plays a role in gene expression as well as activities of multiple enzymes
Deficiency
Very rare
Hemolytic anemia from oxidative damage
Neuromuscular disorders causing neuropathy and myopathies
Sources
Cooking oils, especially olive and sunflower
Nuts and seeds like almonds, sunflower seeds, pine nuts
Vitamin K
Function
Necessary for clotting factors II, VII, IX, X, and proteins C and S
Deficiency
Increased bleeding risk causing bruising, petechiae, hematomas, melena, hematuria
Labs show increased PT and INR, PTT is normal or only mildly prolonged
Overall rare, with the exception of newborns who receive a Vitamin K injection to prevent life threatening hemorrhage
Sources
Green vegetables like spinach, broccoli, and green leafy vegetables
Meats, cheeses, and eggs
Produced by gut bacteria
B1 Thiamine
Function
Involved in TCA and pentose phosphate pathway
Cofactor for enzymes involved in metabolism of carbohydrates and amino acids
Important role in synthesis of GABA and glutamate, as well as myelin sheath maintenance
Beriberi
Infantile - fulminant cardiac syndrome with cardiomegaly, tachycardia, cyanosis, pulmonary HTN; older infants may have neurological symptoms resembling aseptic meningitis (agitation, altered consciousness, seizure)
Dry - symmetrical peripheral neuropathy with sensory and motor impairments, mostly of distal extremities
Wet - cardiac involvement with cardiomegaly, cardiomyopathy, heart failure
Wernicke-Korsakoff
Wernicke - nystagmus, ophthalmoplegia, ataxia, confusion (acute syndrome requiring emergency treatment to prevent death and neurologic morbidity)
Korsakoff - impaired short-term memory, confabulation and confusion (chronic neurologic condition)
Sources - pork, legumes (beans, soybean, chickpeas, peanuts, lentils), enriched cereal or whole grain,
B2 Riboflavin
Function
Essential component of coenzymes involved in cellular metabolic pathways including TCA and beta-oxidation of fatty acids
Redox reactions - FAD
Deficiency
Sore throat, cheilitis (inflammation of lips, causing dryness and cracking), angular stomatitis (sores on corner of mouth), glossitis (inflammation and swelling of tongue)
Seborrheic dermatitis particularly affecting ear, nose, eyelids → red, scaly, greasy
Sources - milk, eggs, meats, green leafy vegetables, fortified cereals
B3 Niacin
Function
Involved in the synthesis and metabolism of carbohydrates, fatty acids, and proteins
Associated with coenzymes NAD and NADP+
Deficiency
Carcinoid syndrome is a paraneoplastic syndrome that occurs secondary to a neuroendocrine tumor
Causes metabolism of tryptophan into serotonin rather than niacin
Hartnup disease - autosomal recessive genetic disorder caused by a defect in a membrane transporter that is responsible for tryptophan absorption as well as other neutral amino acids
Drugs - isoniazid, azathioprine, 5-fluorouracil, 6-mercaptopruine, pyrazinamide
Pellagra - dermatitis, diarrhea, dementia
Dermatitis - symmetric, hyperpigmented photosensitive rash located in sun exposed areas
Diarrhea and vomiting
Dementia - irritability, poor concentration, fatigue, encephalopathy
4 D’s = death
Sources
Meats and fish, nuts/legumes/seeds, fortified foods and cereals
Tryptophan, which is an amino acid, can be converted into niacin in the liver
B5 Pantothenic Acid
Function
Required in order to synthesize coenzyme A, used in TCA
Essential for fatty acid metabolism, as well as proteins and carbohydrates
Deficiency is very rare and has not been studied well, cases of deficiency are mostly from prisoners of war during World War II, victims of starvation, or limited volunteer trials
Impaired energy - irritability, fatigue
Numbness and paresthesias in hands and feet
Animal studies of B5 deficiency showed growth failure, changes in coat color particularly graying, alterations in metabolism, other nervous, GI, and immune system alterations
Sources - eggs, dairy, chicken, beef, potatoes, whole grain
B6 Pyridoxine
Function
Involved in amino acid and lipid metabolism, neurotransmitter synthesis, histamine synthesis, hemoglobin synthesis, steroid hormone modulation
Coenzyme for many reactions including decarboxylation, transamination, elimination
Deficiency
Certain drugs are associated with vitamin B6 insufficiency because they interfere with pyridoxine metabolism, including isoniazid, hydralazine, and levodopa/carbidopa
Seborrheic dermatitis
Atrophic glossitis, cheilosis
Microcytic anemia due to impaired heme synthesis
Neurologic symptoms including somnolence, neuropathy due to impaired myelin synthesis, and seizures
Sources
Meats and fish, veggies, whole grains, nuts
B7 Biotin
Function
Essential cofactor for several carboxylase enzyme complexes which are involved in carbohydrate, amino acid, and lipid metabolism
Involved in protein synthesis and cell replication
Deficiency - rarely occurs because the daily requirement is low, contained in a lot of different foods, and intestinal bacteria synthesize a small amount
Deficiency can occur particularly with egg white consumption due to avidin, a protein that binds biotin
Other risk factors include long term TPN use
Thin, brittle hair → alopecia
Dermatitis, particularly around the eyes, nose, and mouth
Neurological symptoms - changes in mental status, lethargy, hallucinations, and paresthesias
Sources
Egg yolk, organ meats particularly liver, nuts and seeds, meats and fish, yeast
B9 Folate
Function
Essential for the synthesis of DNA, the modification of DNA and RNA, the synthesis of methionine from homocysteine, and various other chemical reactions involved in cellular metabolism
Particularly important for red blood cells
Deficiency
Macrocytic, megaloblastic anemia - large, immature red blood cells
Women with folate deficiency are more likely to give birth to infants with low birth weights, neural tube defects, spina bifida or other brain defects
Vague GI symptoms like diarrhea and anorexia
No neurological symptoms (unlike B12)
Deficiency can be caused by several drugs such as phenytoin, sulfonamides, methotrexate
Sources
Leafy green vegetables
Fortified grain products
Legumes and peanuts
B12 Cobalamin
Function
Cofactor in DNA synthesis
Involved with fatty acid and amino acid metabolism
Involved in myelin synthesis as well as red blood cell formation
Deficiency
Can be caused by
Deficiency in intrinsic factor, which must bind B12 for absorption - pernicious anemia
Decrease in stomach acids which also aid in absorption, therefore can be at risk when taking long term PPI, H2 blockers, or antacids
Megaloblastic, macrocytic anemia
Glossitis (pain, swelling, tenderness, hyperpigmentation)
Non-specific GI symptoms like diarrhea and constipation
Neurological symptoms
Symmetric paresthesias or numbness and gait problems
Subacute combined degeneration - progressive weakness, ataxia, and paresthesias that may progress to spasticity and paraplegia
Non-specific depression, irritability, insomnia, cognitive slowing and dementia
Sources
Meats
Dairy products and eggs
Fortified products like cereals and plant-derived milk substitutes
Strictly in animal products, so diets of vegetarians and vegans may not provide sufficient B12 unless a dietary supplement is consumed
Vitamin C
Function
Involved as a coenzyme in many enzymatic reactions, specifically wound healing and collagen synthesis
Helps with bone, teeth, skin and tendon
Deficiency - scurvy is a disease process that results from vitamin C deficiency
Symptoms are due to unstable collagen and collagen fragility, which can cause leaking of vascular structures
Gingival bleeding, petechiae, easy bruising, hemarthrosis
Coiled and brittle hair with perifollicular hemorrhage
Poor wound healing
Non-specific including weakness, fatigue, muscle cramping, mood disturbances and cognitive impairment
Sources
Citrus fruits
Vegetables like tomatoes, brussel sprouts, cauliflower, broccoli
R3 Small Groups Tox,Tasks,Rashes WITH Dr. Fabiano, Dr. Kein, and Dr. Martella
Task switching
Four responses to an interruption (from cognitive psychology research)
Task-switching: Suspending the primary task to attend to a secondary task
Multitasking: Continuing the primary task while also attending to the secondary task
Acknowledging: Responding to certain prompts with a brief word or gesture
Deferral: Delaying the secondary task until a later time or avoiding the need to deal with it by indicating unavailability, delegating it, or ignoring it entirely
Task Switching vs Multitasking
Task switching is devoting attention sequentially to two tasks that are occurring in parallel.
Multitasking is performing two tasks simultaneously
In studies of emergency physicians, around 70% of responses to an interruption result in a task switch
Multitasking accounts for only 8% of responses to interruption
Multitasking is only truly possible for manual tasks (hand-washing, gathering equipment, etc.) performed in simultaneously with verbal tasks
Costs of Task Switching
Switch cost – a task takes longer to perform than if there was no preceding task switch and the error rate is higher
Mixing cost – completion of the primary task remains slower after a switch than when just one task is performed, even when accounting for the time lost while performing the secondary task
Long-term priming cost – even when performing only one task, responses are slower if another task had just been performed in the previous few minutes
Asteroids and EKGs
Proof of concept one-group pre-test/post-test design done at Ohio State with emergency medicine residents
Comparing resident performance on ECG interpretation with no distractions to their performance on ECG interpretation while playing Asteroids
Attending to the Asteroids game as if it were an important clinical task yielded substantially lower ECG reading scores for everyone, regardless of their Asteroids score or experience with gaming
100% of residents said the game made ECG reading more difficult, most (91.7%) thought task-switching was difficult, and more than half (53%) thought they could improve with practice
Summary
Task switching in the ED is unavoidable and should be considered a core competency of emergency medicine
Task switching has negative consequences for efficiency and increases chance of errors
Deliberate practice may reduce the costs associated with task switching
Palliative Medicine Consultation WITH Dr. Kiser
What is Hospice
A special kind of care that focuses on the quality of life for people (and caregivers) who are experiencing an advanced, life-limiting illness
Life expectancy of 6 months or less
Affirms life, does not seek to hasten or postpone death
Goal to reduce visits to hospital
Hospice care can be provided in several different locations
Levels of Hospice Care
npatient Unit (IPU)
Like an ICU for hospice patients
Acute management of uncontrolled symptoms
Can not stay there indefinitely until death unless they are actively controlling symptoms that cannot be managed in a decreased level of care setting
Home/Long Term Care Facility
Significant burden on family/care providers
Respite Stay
Up to 5 overnights in an IPU or LTC facility
Palliative Medicine Services
HPM teams have time to get to know patients/families and fully explore patient and family goals of care
Multidisciplinary team
MD/DO
APP(s)
Social Worker(s)
Chaplain(s)
Pharmacist*
The Impact
Inpatient - decrease readmissions and cost per day
Outpatient - outpatient decrease admissions and ED visits
Skilled Nursing decreases hospital/ED transfers
Home-based Decrease the total cost of care
P-Cares
Palliative Care and Rapid Emergency Screening Tool
Content validation 2015
Designed to be completable by ED providers using routinely obtained information in an ED encounter to screen for unmet palliative needs
Recognizes that a brief, focused screening tool needed
Should not require additional patient interviews
Recent studies
Palliative Care and Rapid Emergency Screening Tool and the Palliative Performance Scale to Predict Survival of Older Adults Admitted to the Hospital from the Emergency Department. Paske et al. 2021.
Six month survival showed lower survival in those that are P-Cares Positive
Inferred Hazard Ratio increased with those that are Pcares positive
How to Get palliative Care involved
Discuss concerns with patient/family
Consult from the ED
In hospital M-F 0800-1630
Available by phone consultation at other times
ED Contact: Palliative Care
Inpatient Consult to Palliative Care order*
ED social workers/case managers can place hospice referrals for dispo to hospice
Patient being admitted
Suggestion to admitting provider
Offer to place IP consult order
Patient being discharged
Suggestion to outpatient provider(s)
ED Social Worker/Case Manager can place hospice/palliative referrals
