Grand Rounds Recap 01.08.20

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R4 Sim - Cocaine Body Packing WITH Drs. Gauger, Humphries, Jarrell, and Owens

Body Packing

  • Classic patient is a male traveler from a trafficking country in their 30s-40s, but cases have been described in all groups including pregnant women, children, and the elderly.

  • Packers are known to wrap their product in multiple layers of latex and/or aluminum foil and swallow them. They take anti-motility agents until they arrive at their destination and then take laxatives to pass the product.

  • This is different from stuffing. Stuffers tend to wrap their product in less secure packages and insert it into their anus or vagina. These packages are more prone to rupture.

  • Cocaine is the most commonly packed drug, followed by heroin.

  • Cocaine packers typically traffic around 1kg of drug, valued at up to $1 million. For this reason, if you have a patient suspected of packing you should consider heightened security for your ED because someone will likely be looking for that individual.

Workup

  • Because packaging is sophisticated, the risk for rupture and intoxication is actually quite low - only about 3%.

  • X-rays are insensitive, only about 40%. “Double condom sign,” “tic-tac sign,” “parallelism sign,” “dense wrapping material,” and multiplicity of foreign bodies are common xray findings.

  • CT is both more sensitive and specific.

Management

  • Continuous nitroglycerine infusion is a good choice for blood pressure management in cocaine-induced hypertensive emergency.

  • Contrary to dogma, labetalol is safe for cocaine and methamphetamine-induced hypertensive emergency or unstable angina and is approved by recent AHA/ACC guidelines.

  • Charcoal avidly binds cocaine.

  • Whole bowel irrigation is both cathartic and also rapidly alkalinizes the stomach, which can prevent further leaching of packages. Polyethylene glycol will not rupture packages.

  • Endoscopy is essentially never used because of the risk of rupturing a package when trying to remove it.

  • Surgery is indicated if a known packer presents with symptoms of a corresponding toxidrome, high risk of package rupture in a known packing situation, for bowel obstruction, failure to defecate packages after five days, repeated manifestations of opioid toxidrome, or inadequate response to narcan.

  • Asymptomatic patients should be watched for six hours. If still asymptomatic they can be discharged, especially if their packages were wrapped in paper.

R1 Clinical Knowledge - Blunt Carotid Injuries WITH Dr. Gressick

Mechanisms - hyperextension, hyperflexion, direct blow to anterior neck

Consequences - dissection, intramural thrombus, pseudoaneurysm formation, thromboembolic events, and occlusion

Presentation - usually present asymptomatically; ipsilateral headache or horner syndrome most common, otherwise neck pain, ischemic sx, neck pain, tinnitus, or bruit on exam

Screening - important because most patients are asymptomatic

  • Arterial hemorrhage from nose, neck, mouth

  • Cervical bruit <50 yo

  • Focal deficits

  • Stroke on CT or neuro deficit unexplained by CT

  • If yes to any of these get arterial imaging; if none then look at risk factors

    • Facial fracture, petrous bone fractures, diffuse axonal injury confer 41% chance of arterial injury, and if all three then the chance is >90%

    • Some sources say that risk factors are too insensitive and suggest obtaining CTA in any patient with an indication for CT neck or CTA chest

Imaging

  • DSA - gold standard, but not readily available

  • CTA - test of choice because of wide availability, but sens/specificity not 100%

  • Duplex - not useful or recommended for traumatic dissection

  • MRI - better images, but timing and availability are limiting factors

Grading - I-V from luminal irregularity to transection

  • Important because of diagnostic and therapeutic implications, but allow radiologists to make this call

Treatment - depends on grade of injury

  • Grade I antithrombotic therapy only (heparin or antiplatelet) - Note there is still risk of progression despite antithrombotic therapy

  • Grades II - IV operative or endovascular intervention depending on accessibility

  • Grade V (complete transection) - surgery or balloon embolization

Taming the SRU - Sepsis and Comorbidities WITH Dr. Gottula

Sepsis + ESRD

  • Frequent opportunities for infection, sepsis is a leading cause of death in ESRD

    • 50x higher in dialysis

    • Sepsis should be considered the biggest life threat - prompt antibiotics and careful fluids 

      • Under-resuscitation leads to worse outcomes

      • Over-resuscitation leads to complications

      • Resuscitate in smaller increments, reassess frequently, and remember that excess fluid may be dialyzed off

  • Pneumonia and line infections are most common, MRSA is 100x more common

Sepsis + CHF

  • Appearance can lead providers to be less aggressive with fluid, but they’re actually still intravascularly depleted

    • Under-resuscitation leads to higher mortality and higher intubation, with no difference based on EF

    • Patients still remain more susceptible to pulmonary edema and anasarca, so go slower and remember BiPAP

Broader approach to hemodynamics: Consider venous return in addition to BP and stroke volume

  • Traditional approach focuses on left ventricle and arterial physiology

  • We should not neglect the venous circulation - it has 30-times the compliance of the arterial circulation and contains about 70% of the entire blood volume

  • Take advantage of the compliance and capacity - resuscitate appropriately with fluid while using pressors and inotropes to move fluid more effectively through the venous circulation and improve your end-diastolic volume, as this will be the key to improving your left sided function

R4 Capstone - The Hero’s Journey, Finding Your Niche WITH Dr. Ham

Joseph Campbell was an American literature professor best known for his work on comparative religion and mythology and for writing the book The Hero With a Thousand Faces.

In this book Campbell describes what he refers to as the Monomyth, or the Hero’s Journey. This is the set of common themes and archetypes that are found in many of the creation myths and hero tales from cultures spanning the earliest recorded human history through to our modern times.

The Hero’s Journey broadly follows a pattern of stages that Campbell labels separation, initiation, and return. 

In the separation, the hero exists in their mundane condition and has yet to realize their destiny. They receive a call to adventure and are assisted in crossing the threshold from the mundane world into the world of adventure by an experienced guide.

In the initiation, the hero is faced with a series of trials in which they are aided by friends and allies, and ultimately encounters a climactic crisis. They strike a decisive victory and gain some transformative power, knowledge, or artifact.

In the return, the hero goes back to the mundane world but changed by the experiences of the adventure and uses their gifts to change their world for the better.

Finding your niche in life and in your profession is analogous to the Hero’s Journey.

Heeding the call - early on, explore as many opportunities as you can to find out what you are passionate about. As you hone in on this idea, don’t be afraid to decline projects or requests that don’t feed your own goals so that you can focus your energy where it matters.

Seeking your guide - having identified your passion, find a mentor who’s career you wish to emulate, someone whose life has followed a similar trajectory as you would like yours to. As the mentee you should take initiative to seek focused guidance. Finally, understand the difference between a mentor and an advocate - a mentor talks with you about your goals, but an advocate talks about you to other people and helps open doors. Both are critical to your development.

Assembling your allies - you’ve discovered what fulfills you and found a mentor and advocate who can help you along the path. You also need to network to find like-minded individuals to share ideas, enhance your knowledge, and broaden your horizons. Conferences, social events, and social media are all ways to build this network.

Metaphorically speaking, developing your niche is the same as finding the transformative power described by the Hero’s Journey. Just like that power, you can use it to change your world for the better.

Financial Planning WITH Dr. Doerning

Financial planning is a marathon, not a sprint. Almost no one “beats the market,” so be purposeful and informed about your money.

Why are doctors bad with money?

  • We don’t talk about it

  • Careers start late

  • We don’t take training debt seriously

  • Good at calling “consults”

  • Lifestyle creep

  • We’re done with delayed gratification

Running the numbers

  • 70% of docs older than 60 had 1-3 mil saved

  • 56% under 40 have less than $100k saved

  • There are no hard numbers on how much you should have at retirement. It’s based on individual factors (kids, home, lifespan, etc).

If you remember nothing else

  • Save more than you spend

  • Make saving automatic and intentional - payroll deductions, for example

  • Make your money work for you

Making your money work for you - 

  • Cash and cash equivalents don’t appreciate or bring a return - a dollar under the mattress is never worth more than it already is.

  • On the other end, speculative investments can be high reward, but are also high risk.

Stocks, bonds, and funds

  • Stocks - buying a share in a company, depends on investors faith in the company

  • Bonds - a unit of debt from an institution, lower return but generally safe

  • Funds - mutual funds and exchange traded funds - a diverse mix of different asset classes. Combinations of stocks in good companies picked by experts and presented as a package.

Why Funds are your friends

  • Diverse

  • Set it and forget it

  • Active vs passive management - a group of people actively pick stocks and put them in a portfolio vs no active management of the portfolio (more susceptible to ebb and flow of the market, but less expensive)

  • Expense ratio - higher with active management

  • Time in the market is better than timing in the market

What should you be doing right now?

  • Pay someone to do everything? Probably will hurt you in the long run. Advisors typically charge 1%, which over the course of a 30 year career adds up to a huge amount.

  • Do everything yourself? We graduated med school, so we should be able to conquer this.

    • The three legged stool of retirement

      • Employer contributions

      • Personal savings

      • Social security - don’t count on it

Doerning’s Rx for financial health

  • Pay off high interest debt.

    • Make a budget and stick to it.

    • Credit card debt is a killer.

    • Consider refinancing high interest debt (mortgages, student loans, etc)

    • But not all debt is bad. Weight interest rate of debt against interest rate of investments.

  • Build up an emergency fund.

    • Conservative recommendation is to have 6 months of living expenses.

    • High yield savings accounts - Ally, AmEx, Betterment - lots of options.

  • Save for retirement

    • For residents

      • ROTH/Traditional IRA

      • Consider a robo-advisor or traditional broker - betterment and wealthfront; low management fees (0.25%), much less than traditional advisors

    • For attendings

      • Max out all available workplace accounts

    • Invest with your HSA

      • Triple tax advantaged - deposit pre-tax money, medical expenses are not taxed, investment gains are not taxed

      • Max contribution $3550

      • Rolls over every year and you never lose it

      • Pay your financial expenses on a credit card if you can afford it and save the HSA

  • Taxable account investing

    • Invest in index funds, ETFs, etc.

    • Robo-investors like betterment and wealthfront

    • Open a fee-free trading account

      • Robinhood, Schwab, etc.

Immediate steps - do this now!

  • Max out workplace accounts

  • Max out traditional IRA and backdoor into ROTH

  • Max out HSA monthly

Take home points

  • Save more than you spend

  • Make saving automatic and intentional - if you don’t see it, you won’t spend it

  • Make your money work for you

Pediatrics - Difficult Conversations WITH Dr. Willen

Recognize what makes these conversations difficult

  • Peds conversations are family centered, focused on growth and development, and the patients themselves are limited participants

  • Common worries of parents - How will this affect my child’s future? Will they still be able to become independent?

  • Kids can’t consent, but can assent - assess their awareness, expectations, understanding, and willingness to participate

Three elements key elements of having difficult conversations:

  • Building partnership

  • Having interpersonal sensitivity

  • Appropriate level of informativeness

Why it matters

  • Misunderstanding perspectives, failure to solicit values, families’ perception of desertion, and poor delivery of information lead to worse outcomes and higher medicolegal risk.

Why do providers have difficulty delivering bad news?

  • Afraid of being blamed, feeling untaught on how, fear of causing a bad reaction for family, unwilling or unable to express emotion, feel like they are taking away hope, and not wanting to cause depression

How to have a difficult conversation

  • There are several different structured models that can help get through conversations in an efficient manner (Six steps, SPIKES, BREAKS, ABCDE for example)

  • Use direct, but simple language