Grand Rounds Recap 10.31.18

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Pediatric Orthopedics WITH DR. MEHLMAN

Challenges in the Emergency Department with Pediatric Orthopedics

  • Ace Wraps can cause re-perfusion injury, so use sparingly

  • With such variation in extremity size, a study found pediatric splints are improperly positioned as high as 59% of the time

  • Hare Traction splints are too large to effectively use on children

  • Only 27% of MD students consider their musculoskeletal curriculum adequate

  • In pediatrics, the number one cause of law-suits was due to fracture

Cases

Pinckley Lesion and Seymour Fracture

  • A 5y patient presents after twisting his finger during a fall. A small drop of blood is visualized proximal to the nail.

  • This is an occult open fracture just proximal to the nail of the distal phalanx of either finger or toe

  • It deserves reduction if displaced and sometimes pinning, but always antibiotics

Posterior Hip Dislocation

  • A 12 yo M fell after football. He was found to be have a hip dislocation after transfer, initially missed on ED review of films.

  • AVN is in 12% of hip dislocations, 20 times higher risk when reduction >6 hours

  • Requires immediate reduction prior to transfer

Femoral Neck Fracture

  • 9 yo F playing soccer who fell down. Femoral neck fracture appeared on films. With hypotension, a T-pod was placed.

  • No indication for T-pod or other pelvic binding in absence of pelvic ring fracture.  

Posterior knee dislocation

  • 15 yo M playing football was struck in his right knee. Posterior knee dislocation seen on films.

  • 5-64% rate of vascular injury from this. They routinely require transfer for neurovascular monitoring or intervention

Supracondylar Humerus Fracture

  • 5 yo M fell onto left arm. He was found to have supracondylar humerus fracture. Child had high median nerve palsy (flexor digitorum superficialis loss).

  • High median nerve palsy (inability to move FDS fully to do “OK” sign) should raise suspicion for a silent compartment syndrome and deserves immediate transfer for monitoring

  • Pucker sign (area of tissue retraction in the AC fossa) associated with neurovascular injury and pulselessness, indicative of a higher energy injury

  • Soupy pins after reduction are signs of septic arthritis in supracondylar fracture until proven otherwise.

Monteggia Fracture

  • 5 yo F presents after fall on his arm. Olecranon fracture noticed on initial x-ray. Missed Monteggia fracture with radio-capitellar dislocation.

  • Radius should point directly at the capitellum though the range of motion in AP and lateral views.

  • Initially missed dislocation will need operative repair due to difficult reduction.

Leadership Curriculum- Recruitment and Team Building  WITH DR. STETTLER, FERMANN, and MCDONOUGH

Recruitment

  • Recruitment starts with identifying qualities that you are trying to recruit

    • Know your mission

    • Work with your existing team to understand who will help you deliver this mission

    • Figure out what speaks to people to recruit them

  • Philosophies of recruiting

    • Diversity helps build strength in the department

    • Not only diversity of age, sex, gender, race, but also diversity of thought, skills

  • Recruiting successes

    • People want to be able to able to envision themselves in the organization

    • People want an organization that will invest in them

    • Institutional pride should be present, but understated

  • Case:

    • You are a senior resident who is working on a research project. However, you have accepted another administrative role and would like to recruit another resident to help complete this research project.

    • Two methods: sending out to an entire group and soliciting interest, or personally seeking out individuals

    • Sending out to the entire group allows equal opportunity, self-selects interested individuals, but does not allow you to select your exact partner

    • Personally seeking out individuals allows you to pick a teammate personally, but may lead to resentment for those who aren’t given the opportunities, and makes the assumption YOU are the best person to select your partners

Building a Team

  • To build an effective team, you must know your mission, define roles, empower success, and provide feedback

    • Know Your Mission

      • To know your purpose, you must know your goals

    • Define roles

      • Define roles, with flexibility

    • Empower success

      • Allow your team to grow personally and innovate

      • Provide honest feedback, both positive and constructive continuously

      • Listen and consider

    • Providing feedback

      • This is your primary role as a leader

      • Have your team-members provide feedback in order to identify problems early, and provide solutions

  • Case: You are a resident leader who is part of a small group of residents tasked with re-designing flow and process of resident graduation. You are having a tough time deciding the details. How do you bring a team together to craft solutions?

    • Consider the number of individuals needed in the group. Too few limits diversity of opinion, too many impedes progress.

    • Consider creating subcommittees for separate missions to maximize efficiency.

    • Setting goals and metrics by which to measure achieving those goals will allow more productivity in meetings

Opioid Overdose Prevention Programs WITH DR. JARRELL

Public Health and Social Emergency Medicine

  • Emergency medicine is uniquely positioned as a specialty to conduct surveillance and research on population health needs

  • Public Health and Social EM Group is forming to help facilitate communication, collaboration, and career development in this area as well as provide content to all residents on this focus area

Community Opioid Overdose Prevention Programs (OOPPS)

  • Overdose deaths doubled from 2010 to 2016

  • Community Opioid Overdose Prevention Programs distributing Narcan can save lives

    • In a meta-analysis of 11 studies, 100% of patients’ overdoses survived, and 2 studies showed a correlation of OOPPs with lower death rates

    • Bystanders respond correctly more frequently correctly (moving to naloxone administration) in communities with OOPPS

Narcan Distribution Collaborative

  • This is a local partnership between social service agencies, and hospital systems to saturate the community in naloxone in Cincinnati

  • We have handed out 8k doses in the community, but only ~200 are from the ED

  • 34% of people who collected narcan did so in case they overdose, 28% want to use it on family/friends, 46% want to use it if they see somebody who overdoses

Opioid Use Disorder Epic Tool

  • Referrals to Addiction Sciences have nearly tripled since implementation at UCMC

  • The total number of patients engaged in treatment has not significantly increased

  • The number one barrier to this is 71% of patients can’t be reached

    • Ensure you are telling patients about the referral, and they have given their correct phone number

Hernias WITH DR. LEECH

Types      

  • Groin Hernias

    • Inguinal hernia- Most common type of hernia, hernia through the inguinal canal

    • Femoral Hernia- Hernia below the inguinal canal

  • Incisional hernia- Can be through linea alba or previous weakened surgical closures of the abdomen

  • Umbilical hernia- Hernia through the weakness in the site of passage of the umbilical cord

  • Hiatal- Hernia of the stomach sliding up through the diaphragmatic wall into the thorax

Status of Hernia

  • Reducible

    • Soft, easy to push in

  • Incarcerated

    • Bowel is stuck through the hernia defect, difficult to reduce, but not ischemic or infarcted bowel

    • Contents are soft, may hear bowel sounds, no overlying bruising

  • Strangulated

    • Bowel ischemic or infarcted

    • Toxic appearing, tense hernia, overlying bruising and erythema

Physical exam

  • Examine both standing and lying as it may make more apparent

  • Assess fascial defect

  • Look for overlying skin changes which will help differentiate between incarcerated vs strangulated

Imaging

  • KUB not sufficient to rule out SBO

  • Ultrasound can help quantify the size of the fascial defect and see contents, however limited in assessing flow

  • CT scan is the standard of care for detecting SBO

Treatment

  • Definitive treatment is surgical repair

  • Reducible- elective repair

  • Incarcerated- 1-2 attempts by ED, then consider consultation of ACS, if successfully reduced - elective repair and return precautions

  • Strangulated and/or bowel obstruction- Surgical repair

Wellness Curriculum WITH DR. JARRELL AND DR. BANNING

What we are doing well

  • We have a family in our department

  • We emphasize a shared mission

  • We have good relationships with our coworkers

Things We Continually Improve

  • Planning activities for the sake of wellness sometimes ignores the more systemic problems causing people to be unwell

  • Wellness activities that make you well both at work and outside it. By emphasizing what you find meaningful in both of those realms, is a very personal thing but what we intend to support as a program

 Intentional Integration

  • Wellness must be an active and intentional process by the individual

  • Intentional and progressive integration of wellness inside and outside of work is what causes change