Grand Rounds Recap 7.24.19

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Leadership CurriculuM: Attitudes of A Leader WITH DR. Hill

  • The Pyramid of Success by John Wooden

    • Cornerstones of success as a leader are enthusiasm and industriousness

    • Second layer includes components related to self-control and consistency

    • Third layer focuses on condition, skill, and team spirit

    • The top layers emphasize poise, confidence, and competitive greatness

  • Theory on leadership has changed over the last century to focus on leadership as a learned skill that requires maintenance of traits that contribute to leadership abilities

  • Five facets of personality and attitudes that contribute to leadership

    • Neurotocism - the tendency to exhibit poor emotional control

      • This is negatively associated with leadership effectiveness

    • Conscientiousness, which includes achievement and dependability

    • Extraversion

      • This facet has the strongest correlation with leadership effectiveness

    • Agreeableness

    • Openness to experience

  • Heitz et al, 2011

    • Most important skill sets to obtain prior to becoming a chair

      • Prior academic experience

      • Formal training

      • Previous academic leadership experience

      • Managerial experience

    • Based on this study, we performed a similar survey at UCEM

      • Five Most Important Traits: effective communicator, collaborative, trustworthy, effective decision maker, problem solver

      • Five Least Important Traits: curious, sense of humor, charismatic, idealism, entrepreneurial

  • Furtner et al, 2017

    • The Dark Triad

      • Narcissism

        • Can be positive, but mostly negative trait with a fair amount of grandiosity and arrogance

        • There is unrestrictive desire for appreciation and acceptance

      • Machiavellianism

        • Self-promotion and self-aggrandization are not ultimate goals but rather means to another end

        • Individuals with this trait must plan, organize, and control

      • Psychopathy = dysfunctional impulsivity

Taming the SRU: Fat Embolism Syndrome  WITH DR. Hughes

  • This is a case of a morbidly obese patient with mangled extremities who becomes hypoxic requiring intubation and eventually dies. Autopsy eventually showed fat embolism.

  • Debriefing = “facilitated or guided reflection in the cycle of experiential learning”

    • Benefits

      • Leads to future improved efficiency

      • Better patient outcomes

      • More accurate information

    • Hindrances

      • Insufficient time

      • Lack of trained facilitators

      • Lack of debriefing setting

    • Tips on Successful Debriefing

      • Encourage the resident or nurse documenter to lead the discussion to level the discussion from hierarchy

      • Focus on the processes and structures, not the outcome

      • Review what went well, what didn’t, and the delta

  • Fat Embolism Syndrome

    • Pathophysiology: not entirely known, but fat obstructs pulmonary vessels either primarily or secondarily leading to a profound inflammatory response

    • Triad: petechial rash, respiratory symptoms, neurologic symptoms

    • Eriksson et al, 2011

      • Likely under diagnosed in trauma patients, especially within the golden hour

      • 82% had fat embolism on autopsy

    • Treatment

      • No data to support specific treatment regimens

      • Supportive care includes: mechanical ventilation, vasopressors, and ECMO

    • Prevention

      • Surgical fixation of long bone fractures within the first 24 hours

      • Consider steroids, such as low dose methylprednisolone, although data admittedly limited

  • Take Home Points:

    • Leadership requires vulnerability.

    • Encourage the use of and feel empowered to lead debriefs.

    • Think of fat embolism syndrome in hypoxic trauma patients without evident source

R4 Case Follow Up: Streptococcal Toxic Shock Syndrome WITH DR. Spigner

  • This is a case of a young female with abdominal pain found to be severely leukopenic with a CT scan concerning for appendicitis. She was eventually diagnosed with Group A strep bacteremia and grossly contaminated ascites.

    • Her course was complicated including septic shock requiring vasopressors, intubation and multiple operations.

  • Streptococcal Toxic Shock Syndrome

    • Higher incidence in elderly patients and children

    • No source of infection identified in approximately half of cases

    • There is an association with other viral infections, such as EBV, influenza, and varicella

    • Diagnostic criteria include hypotension and multi-organ involvement with isolation of GAS from sterile sites

    • Risk is 20x higher in pregnant patients

    • Many case reports of patients with GAS bacteremia initially being diagnosed as having appendicitis

    • Treatment:

      • Broad empiric antibiotic coverage

      • Clindamycin should be used in combination with beta-lactams for treatment as it can tamper toxin release

        • Penicillin monotherapy has been associated with higher morbidity and mortality in infections with toxin production

      • IVIG can be considered as an adjunct, based on Parks et al 2018

    • Prophylaxis

      • Household contacts should be treated with 10 days of penicillin or clindamycin to clear asymptomatic colonization given invasiveness of GAS strain

Simulation and Oral Boards

  • Simulation: This is case of a patient with bradycardia, refractory hypoxemia, and hypotension. He was found to have signs of right heart strain with McConnell sign on bedside cardiac ultrasound. After intubation, he suffers cardiac arrest with persistent refractory hypoxia. After ROSC, CTPA and CT abdomen/pelvis negative.

    • Diagnosis: PFO with R to L shunt and Eisenmenger Syndrome

      • Right Heart Failure without PE

        • If patient has been stable with significant hypoxia, it may be reasonable to allow permissive hypoxia rather than intubating, as that will worsen the patient’s right heart failure.

        • If requiring intubation, prepare for significant hemodynamic compromise

        • Would use a systemic vasopressor with a venodilator, like dobutamine

        • Gentle fluid resuscitation

        • Use as little PEEP as possible

        • Consider epoprostenol or an inhaled pulmonary vasodilator like nitric oxide

      • Refractory hypoxemia with clear CXR and no PE, think shunt

  • Oral Board Case

    • Young female h/o DM with four days of pain and decreased visual acuity in right eye.

    • Right eye with injection, EOMI, PERRL, visual acuity 20/40 (L 20/30), no sinus tenderness, IOP 18 bilaterally, consensual photophobia

    • Slit lamp exam: cell and flare

    • Dx: anterior uveitis

    • Tx: steroid drops, consider cycloplegics, facilitate ophtho follow up

    • Consider autoimmune etiologies for a patient with recurrent symptoms of anterior uveitis