Grand Rounds Recap 3.4.20
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Climate Crisis and Clinical Practice - Implications for Emergency Medicine WITH Visiting Lecturer Dr. Renee Salas
There has previous been lack of engagement around climate change and its effect on health because it doesn’t seem personal
Terminology
Sequestration: removal of carbon, which includes putting carbon back into the ground from the atmosphere
Mitigation: decreasing production of carbon emissions
Transportation and electricity remain the biggest contributors to carbon emissions
Health care systems contribute 10% of greenhouse gas emissions in the US
Human drivers are also contributing to increases in global temperatures
Currently, we are one degree Celsius above pre-industrial temperatures
Paris Agreement: try to keep temperature at 1.5 degrees Celsius above pre-industrial average
In order to accomplish this, carbon emissions need to be cut in half by 2030 and must be net zero by 2050
Current policies project temperatures will increase by about 3 degrees Celsius by the end of the century
Climate change will affect various locations and people differently
Increasing temperatures by 2 degrees Celsius will cause coral reefs to become extinct and the number of people being exposed to extreme heat will double
The number of billion dollar climate disasters have been increasing with at least 10 per year over the past 5 years
Effects of climate change
Heat
Increased episodes of heat stroke
Linked to increase pre-term delivery and low birth weight
Exacerbates mental health issues and has been associated with rise in suicide
Trauma volume tends to be higher
Increase in annual extreme temperature mortality
Air pollution and air quality
Can cause increased cardiovascular and cerebrovascular issues
With increased CO2, pollen levels have increased and will cause an increase in ED visits for asthma
Food supply
Crops are less nutritious when grown in higher CO2 environments
Floods and droughts will make it harder to grow crops
Water
Many water-borne disease are climate sensitive
Vibrio is more suitable in increased water temperatures
Extreme weather events
These events have many psychiatric sequela, which are being termed eco-anxiety or eco-grief
Vector-borne diseases
Diseases transmitted by ticks and mosquitos have tripled
Lyme disease diagnoses are on the rise
Social factors
Migration and displacement related to extreme weather events may cause increased crowding
With extreme weather events, patients have problems accessing medications, seeing doctors, and affording health care
Lancet Countdown
220 million additional vulnerable people were exposed to extremes of heat in 2018
133 billion potentially work hours lost due to rising temperatures across the world
This impacts the southern US to a greater degree
There is increasing coal usage across the globe
Fossil fuel subsidies increased in 2018
Most of the public have not made the connection between climate and health
What can we do in emergency medicine?
Use narrative story telling to describe the link between climate and health, for example:
Talk to athletes about the increasing frequency of heat waves because of climate change and how to recognize heat emergencies
Talk to patients with asthma to look at pollen levels before spending time outdoors and how pollen levels are rising because of climate change
EM providers are experts in leading interdisciplinary teams
Reach out to local politicians to discuss climate change policy
Work to make hospitals more eco-friendly
Utilize patient handouts when possible
Other potential ways to have impact:
Clinical practice and care delivery improvements
Personal lifestyle changes
Public health adaptation
Climate crisis research lens
Advocacy and outreach
Health care sustainability
Civil disobedience
Divestment
Education, including free courses below
Health Effects of Climate Change at Harvard
Ultrasound M&M WITH DR. Baez
Takotsubo Cardiomyopathy
Most commonly found in post-menopausal women
Mayo Clinic Criteria
Transient hypokinesis, akinesia, or dyskninesis of LV mid/apical segments
On echocardiography, look for hypokinesis of the apex or mid segment on the apical 4 chamber view
LV dysfunction must resolve within 8 weeks, typically 4-6
Absence of obstructive CAD
New EKG abnormalities
Mostly ST elevation in anteroseptal leads although can be variable
Absence of pheochromocytoma and myocarditis
Stressful triggers are often identified, but not mandatory for diagnosis
Optimizing Gallbladder Imaging
Position the patient in the left lateral decubitus position
Use the curvilinear probe, although can use phased array if needing to image through intercostal spaces
Use the liver as a window
Don’t be fooled by:
Contracted gallbladder, as this may increase the thickness of the gallbladder wall
Bowel (specifically duodenum)
If full of gas, will have a dirty shadow
Wall echo shadow sign if the gallbladder is full of gallstones
Porcelain gallbladder, in which you will just see a lot of shadowing posterior to the gallbladder without visualizing the contents of the gallbladder itself
These patients need confirmatory CT imaging
Ultrasound for Pneumothorax
CXR has 52% sensitivity, 100% specificity for identifying pneumothorax
US has 88% sensitivity, 99% specificity for identifying pneumothorax
B lines rule out pneumothorax
Can also use M mode to help identify “barcode sign”
False positives can be caused by:
Breath holding
Mainstem intubation
ARDS, COPD or other severe underlying lung disease
False negatives can be caused by:
Very small pneumothorax
Lung pulse sign, typically related to beating heart
Ectopic Pregnancy
Interstitial pregnancy: gestational sac in interstitial portion of fallopian tube
Represents 1-11% of all ectopic pregnancy
Constitutes 20% of all deaths from ectopic pregnancy
Risk factor: prior salpingectomy on the ipsilateral side
Measure endomyometrial or myometrial mantle:
ACEP guidelines indicate endomyometrium less than 5-7mm is concerning for interstitial ectopic pregnancy
Recommendations from other groups include:
Less than 5mm: consult gynecology
5-8mm: arrange close follow up
Greater than 8mm: not concerning for interstitial ectopic pregnancy
Angular pregnancy: intra-uterine pregnancy located in the lateral angle of the uterus
Cornual pregnancy: gestational sac in cornu of uterus
QI/KT: Non-Pregnant Vaginal Bleeding WITH Drs. Frederick and Walsh
This presentation goes through QI Committee and will result in a formal algorithm in the EmergencyKT section of TamingtheSRU
Thirty percent of women will experience abnormal uterine bleeding during their lifetime
Etiologies
Systemic
Hypothyroidism
VWD
Hemophilia
Liver disease
Anticoagulation use
Non-Uterine GU Tract
Lacerations and abrasions
Foreign body
Infection
Malignancy
Uterine Bleeding
Structural vs. functional
Ovulatory vs. nonovulatory
History
Normal ovulatory bleeding
Less than seven days of bleeding
Less than 80mL per menses
Frequency of 24-38 days
Abnormal ovulatory bleeding
Needing more than one product (tampon or pad) per hour
Treatment Options
NSAIDs
Cochrane: less effective than TXA, better than placebo
Contraindications: renal disease, peptic ulcer disease
TXA
TXA 3.9g/day for five days vs placebo
Significant reduction in blood loss and no increase thrombotic events
Contraindications: current OCP use, current thromboembolic disease
Side effects: impaired color vision
Progesterone (e.g. medroxyprogesterone) and Estrogen (e.g. estradiol)
Similar outcomes between progesterone and estrogen OCPs with slightly increased cessation of bleeding at 14 days with progesterone
Contraindications of progesterone
h/o DVT/PE
Breast cancer
Liver disease
Rifampin usage
Seizures on certain AEDs
Contraindications of estrogen
Post-menopausal
h/o DVT/PE
h/o stroke
Ischemic heart disease or high risk for atherosclerosis
Tobacco use > 35 years old
Uncontrolled hypertension
Breast cancer
Peripartum cardiomyopathy
Migraine with aura
Significant liver dysfunction
Anti-retroviral therapy
Rifampin
Seizures on certain AEDs
The CDC publishes an extensive list of contraindications and warning to various types of contraception
Supplemental iron for everyone
Final recommendations for treatment includes:
Ibuprofen 600-800mg q8hrs
TXA 1.3g TID for five days
Medroxyprogesterone 20mg TID for 7 days then daily for 3 weeks
OCP with 35mcg ethinyl estradiol TID for 7 days followed by daily for 3 weeks
For severe bleeding
Obtain labs
Type and screen
CBC
Lactate
VBG
Pregnancy
PT-INR
Fibrinogen
Consider TEG and LFTs
Manage hemorrhagic shock with blood products
Stop bleeding:
DeVore et al studies the use of IV Premarin
Reduced bleeding compared to placebo at eight hours
Significant risk of thromboembolic disease
No studies looking at IV TXA in this setting, but has been promising in postpartum hemorrhage
Do not combine with IV estrogen
Consult gynecology for operative management
Vaginal packing
Kerlex covered in Surgilube
Interuterine tamponade with 26F Foley balloon
Clamp urine port
Place speculum
Remove clot
Gasp anterior lip of cervix with ring forceps
Clean cervix with betadine x3
Insert Foley into the uterus
Inflate with 30cc saline
Confirm placement with ultrasound
R4 Capstone: HOw to make effective PResentations WITH DR. Klaszky
Preparation
For 1 hour of lecturing, expect to take 10-20 hours of work
Tell a story
Use a document to type what you want to talk about
Then figure out how to format that onto a more typical layout, like PowerPoint
Use a classic story-telling format
Strong Opening
Interesting Middle
Strong Finish
Slides
Keep it simple
Theory of Multimedia Learning
Coherence Principle - cut out every thing that makes your slides busy or hard to read; simple backgrounds; high contrast colors
Modality Principle - learners cannot read and listen at the same time, try to replace words with images
Signaling Principle - when discussing an image that is important, only place the image on a slide and get rid of the text
When presenting data, create your own graphs to represent the data that is important rather than taking a screenshot of a large table of data
Practice
Present in the actual space you will be in
Get out from behind the podium
Move to a different area when making a transition without constant wandering
Presentation Skills
Perform centering exercises to help with anxiety about your presentations
Visualize yourself giving an amazing presentation
Power posing: stand like a super hero immediately before your lecture
This has been shown to improve job interview performance
Alter tone and pitch as if conversing normally
Pause after you say something important, allowing audience to acknowledge what you said, process it, and think about it
Global Health Grand Rounds: Coronavirus WITH Dr. Calhoun
Dr. Calhoun will send updated information regarding UC Health policies about potential coronavirus infections. For up to date information nationally check the CDC site
