Grand Rounds Recap 11.04.2020

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EMS Grand rounDs WITH dr. Morgan

Community Paramedicine and Mobile Integrated Healthcare

Levels of prehospital providers (course hours - skills):

Emergency Medical Responder: 40 hours - CPR and First Aid

EMT-Basic: 120-150 hrs - assist in meds and basic airway

Advanced EMT: 300-350 hrs - start IV and advanced Airway

Paramedic: 1200-1800 hrs - pacing 12-lead, IV/IO?IM, needle decompression, surgical airway

Community paramedic: state licensed EMS professional that has competence in transport and enhances access to primary care. Also, integrates with public health agencies

Mobile Integrated Healthcare: provision of healthcare using patient-centered, mobile resources in the out of hospital environment, can include:

  • Advice to 911 callers instead of dispatching a unit

  • Chronic disease management

  • Preventive care or post-discharge follow up visits

Initially established in rural areas for remote areas

  • Emerged in response to TB epidemic to distribute Abx in 1950s

  • Federally funded in 1968

  • Community Health Aides and Practitioners Program (CHAP) program employs people to do this 

    • 4 sessions of curriculum and a preceptorship.

    • Acute care, emergency care, follow-up care for patients with chronic illnesses, preventative illnesses

    • Under the medical direction of licensed physician 

    • Improvement in both the infant mortality rate and immunization rate 

1993, Red River Fire Department: the first fire department in the US to establish a community paramedicine program

Remote northern New Mexico town with a population of 500-1000, nearest hospital is 38 miles away

  • 5 paramedics were trained by doctors and other providers

  • 380 classroom hours and 600 hours of clinical training 

  • 78 protocols covering various treatments and scenarios (long-term care for HTN, DM, EtOH, family planning, advanced wound care)

  • Did not dispense meds or write prescriptions

  • Med Director reviewed all run reports that were mailed to his Santa Fe office

  • Ceased operation in 2000

    • Reduced ambulance transports from 78-11%

    • Discontinued due to: 

      • Concerns over inadequate supervision

      • No continued clinical reassessment or education/training

      • Limited knowledge of services provided in community

APP and EMS: Los Angeles created NP1

  • Staffed by NP and FF/NRP (4 days a week, ten hour shifts)

  • In an area with the highest number of involuntary psych holds and 2nd most frequent location of high-911 utilizers

  • POC iSTAT, Sonosite, suturing materials, tetanus

  • May either electively respond or be summoned on scene by other responding units

  • Patients can be dispositioned to: 

    • Social service organization to provide close follow up and linkage to care. 

    • If medically cleared, mental health patients can go to an acute psychiatric hospital

  • All of the patients evaluated by the NPRU have a phone call follow up

  • Treat and release rate of 52% in the first 6 months

SOBER Unit - LA Fire department: nurse, case management, paramedic

  • Take the patient to a sobriety center and start detox

  • Over 100 people to the center

Community Paramedicine in Canada: Nova Scotia

  • NP and Paramedicine physician model

  • Many skills including CHF assessment, flu shots, B12 shots, car seat installation

  • 25% decreased ambulance transport

PERIL Decision tool:

  • Assessing elders at risk of independent Loss tool

  • 3 questions:

    1. Are there problems with the home situation that would prevent patient from being safely discharged home from the ED?

    • 911 use in the past 30 days?

    • Patient has unmet needs for social support that will contribute to recurrent EMS use?

  • Number of answered yes is predictive of adverse outcomes at 30 days (return to the ED, admission, death)

    • 2=54-68% adverse outcome

    • 3 is a 93% adverse outcome

Australia: Queensland and New South Wales: 9 week highly integrated course conducted within the clinical medical school environment

  • Phlebotomy, ABG sampling, UA, Aseptic techniques

ET3 Model

  • Current payment model for EMS is based on misaligned incentives

  • Funding for taking patients to higher acuity settings than where they should go

  • 560 million savings per year by transporting individuals to doctors offices rather than a hospital ED

  • Estimated to save up to 45 minutes of EMS response time

  • ET3 is a voluntary 5-year payment model that will provide greater flexibility to ambulance care teams

  • CMS will pay participants to: transport to an alternative destination partner

  • Initiate and facilitate treatment in place with a qualified health care partner, either at the scene or via telehealth

  • CFD was selected to be in this program, will start in Jan 2021

  • Funding will be through reimbursements by CMS based on level of care and mileage

  • Can treat via telehealth, even during off hours (will allow for increased payment for provider)

r4 case follow up - coping with loss in the ed WITH dr. mand

Impact loss has on ED Physicians: Especially in pediatric deaths

  • 62% say pediatric death is very stressful

  • 64% have feelings of guilt or inadequacy

  • 47% feel impaired during remainder of shift

  • 12% affected their family life

Survey of faculty across the country: 

  • Sense of failure

  • Decreased effectiveness on shift

  • Bad decision-making in the rest of clinical encounters

  • Psychological impairment - desire to seek counseling 

  • Early career burn out

Clinical experience matters: Early experiences are emotionally powerful

  • Junior residents have more emotional powerful experiences, which are often more negative 

    • Often their first intense patient encounter

    • Minimal training on how to manage this

    • If they reach out to faculty after the fact:

      • They are more likely to have more insight in the future

Coping strategies:

  • Talking to colleagues, friends and family

  • Exercise

  • Meditation

  • EtOH

  • Prayer or religious outlets

  • Similar to UC faculty and residents

  • On shift: 

    • The debrief - create a dialogue 

      • Regroup and reflect

      • Understand the case and why it was led a certain way

      • Learn how to function in a team

      • Can enhance individual and team performance

      • Goal to achieve intellectual and emotional closure

      • Helps normalize the experience

      • Improved perception of support

      • Increased connection and satisfaction within the team

    • The pause - structured invitation to stop and honor a patient that has just died under their care

      • Allows individualization of what the pause means for the provider

      • 79% reported improved closure

      • 73% instilled sense of team effort

      • 82% reported improved professional satisfaction

UC Faculty Pearls: 

  • Remember you are human, allow yourself to care and seek help if needed, talk about it and don’t fear formal counseling

  • Be as kind to yourself as you would be to others

  • Unreasonable that your practice will not be error free

  • It is NEVER a weakness to ask for help

  • Have things that give you joy and make these a priority in your life

R1 clinical treatments - dental infections WITH dr. kletsel

Check out Dr. Kletsel’s full post here 

738,000 visits in the ED annually or 0.7% of all ED visits

As common as Painful Urination as CC

Irreversible pulpitis: inflammatory response of the pulp - loss of tooth enamel integrity, direct communication b/w oral environment and the dental pulp

  • Present with sensitivity of cold/heat or swell/sour stimuli - pulp becomes incapable of healing

  • Does Pen VK help? 2000 Randomized Controlled Double Blinded study: 

    • Patents kept a 7-day diary of their pain

    • No difference in pain or doses of ibuprofen

    • 2019 ADA recommends not giving oral Abx

    • Ideally need dental follow up within a few days

*It is hard to extrapolate dental studies to the ED as we do not know the patient’s ability to see the dentist in a timely manner

Periradicular Periodontitis: extension of pulp disease - inflammation and/or necrosis into tissues surrounding the root and apex of the tooth

  • Abrupt onset of pain, exacerbated by biting or percussion of the tooth

  • 2001 study looking at does PCN improve pain? Randomized Placebo-Controlled Double-Blind study

    • No difference in pain rating, or in swelling or in pain medication use

    • ADA states no need for systemic antibiotics, but reasonable if definitive dental care is not available. 

    • Follow up within a week 

Periapical abscess: collection of pus at the apex of tooth

  • Pain on percussion of the suspected tooth, swelling of the gingiva, may also have a draining fistula adjacent to the effected tooth

  • 2005 Observational Study: do antibiotics in addition to drainage help symptoms? 

    • 99% of patients had a clinical improvement after an I&D at bedside

    • No significant difference in scores between the different antibiotic regimens (Pen VK or Augmentin)

  • 1996: Prospective Randomized Double Blind Study after 72 hours improvement in symptoms?

    • No significant difference in self-reported pain or swelling

  • ADA only antibiotics if no I&D done

Deep Neck Space Abscess: most common comorbidities are tobacco and EtOH use disorders

  • Most have swelling and fever

  • Require admission and IV antibiotics and surgery

  • Polymicrobial with a majority of the bacteria being anaerobes 

  • Mean of 7.5 bacterial strains per patient

  • ADA: po amox, pen VK if there are sick patients w/ a periapical abscess

  • >80% were found to be sensitive to all antibiotics

  • Resistance to Pen VK was 19%

  • Amoxicillin is considered 1st line

    • More readily absorbed in the GI tract and in the plasma

    • Clindamycin is the next choice

CPC - posterior mi WITH dr. goff

Posterior MI 

  • 15-20% are associated with inferior or lateral MI

  • Isolated PMI of ~3% of all acute MIs

  • On the EKG: 

    • STD in V1-V3

    • Lack of obvious STE make it an often missed diagnosis

    • If EKG is flipped looks like STE

  • Posterior 12-lead 0.5mm of elevation is diagnostic

    • V7 – Left posterior axillary line

    • V8 – Tip of the left scapula

    • V9 – Left paraspinal region

r4 simulation and oral boards WITH drs. gottula, jensen, lane

Simulation - Hydrofluoric Acid Exposure

  • More toxic if:

    • Higher percentage concentration

    • Longer exposure

    • More body surface area involved

  • Distinct features: 

    • Very lipophilic and being a weak acid allows deeper penetration into the skin,

    • The fluoride ion is very dangerous

      • F causes a lot of electrolyte abnormalities: HypoCa, HypoMg

      • Leads to lengthened QTc and classically Torsades

      • Arrhythmias are the primary cause of death in HF exposure

  • Risks for exposure:

    • Semiconductor and aluminum industries

    • Rust removers

    • Aluminum cleaners

    • Tire cleaning agents

  • Treatment: 

    • Important to do decontaminate w/ vinyl gloves with lots of water

      • HF penetrates latex

    • Calcium

      • Topical calcium gluconate and KY Jelly to mix it as a slurry to apply

        • This reduces pain

        • Can try massaging it as the patient tolerates

      • Intra-arterial therapy: 

        • For high concentration burns to the digits

        • 10% calcium gluconate in LR and infuse over an hour

        • In uncontrolled case series it has added some benefit

  • Systemic toxicity

    • Exposure to >50% concentration or BSA >50%

    • Profound hypoCa and hypoMg

    • Prolongs QRS and QTc leading to torsades

    • Lidocaine is the anti-arrhythmic of choice, Amiodarone prolongs the QTc

    • Important to remember to treat the torsades as you would for any other cause:

      • electricity and magnesium

      • 4g load and .5-1g per hour

    • Overdrive pacing at 90-110: especially if people are going into recurrent torsades

      • goal to shorten the QT

Oral Boards - Anterior Uveitis

  • 4 days of R eye pain with redness and pressure that is worsened by light

  • PMH: DMT2, HLD

  • Physical Exam:

    • Normal IOP and Visual acuity.

    • EOMI

    • Consensual photophobia if the L eye is tested with light

    • No fluorescein uptake

    • Slit lamp: cell and flare in the R eye

  • Treatment

    • Cyclopentolate drops

    • Discuss with ophthalmology about steroids and follow up

Oral Boards - Finger Pain Triple

Case 1 - Flexor Tenosynovitis

  • 30 yo male with 24 hours of finger pain that began after cleaning his fish tank

  • Physical Exam: 

    • Swelling to right middle finger

    • Tenderness over flexor tendon

    • Pain with extension

    • No open injuries

    • Normal capillary refill

  • Treatment

    • Abx with MRSA and pseudomonal coverage

    • Pain control

    • Consult hand

Case 2 - Paronychia 

  • 25 yo female with 24 hours of finger pain, does bite her nails

  • Physical Exam:

    • Tenderness and erythema over the proximal nail fold 

    • No pain with range of motion

    • No spontaneous drainage

    • No tenderness elsewhere

  • Treatment

    • Anesthetize and perform an I&D

    • Abx: GP and anaerobic coverage (for nail biting as the risk factor)

      • Clinda or flagyl +Bactrim or Doxy

Case 3 - Herpetic Whitlow

  • 25 yo female dental student with 2 days of finger pain with a pimple

  • Physical Exam:

    • Pad of the finger is erythematous and tender

    • 3-4 blisters with a small amount of fluid inside

    • No pain with ROM

    • Brisk capillary refill

    • No purulence or drainage

  • Treatment

    • OTC pain control

    • Topical or po acyclovir or valcyclovir