Grand Rounds Recap 6.29.2022

/

HISTORY OF EM WITH DR. PANCIOLI

  • The first group of non-residency trained ER physicians was created in 1961 in California.

  • The first description of CPR was in a 1966 edition of JAMA, along with an article entitled The Emergency Department Problem where it was quoted, “For many years, the emergency service has been the most neglected and often the weakest department in the hospital.”

  • Bruce Janiak became the first EM Resident in the country starting his residency in 1970 at the University of Cincinnati  

  • The American College of Emergency Physicians (ACEP) was established in 1968 and a year later the first EM resident, Bruce Janiak, was trained.

  • Fifty-two years ago, in 1970, the first EM residency was created right here at the University of Cincinnati! 

  • Back in the day of physical charts, there were individual boxes for surgery and medicine patients; “combining of the boxes” was the first step to expanding the scope of practice of EM physicians. 

  • Timeline

    • 1968 ACEP forms with 8 doctors

    • 1974 ACEP moves for a BOARD and 1980 ABEM 

    • 1979: Emergency Medicine was initially a joint board certification

    • 1980: ABEM First Board exam 

    • 1982: ACGME approved residencies in 1982

    • 1984: UCMC Air Care is born 

    • 1989:  Primary board certification (For reference, the first specialty to be board certified was ophthalmology in 1917.)

  • There has still been friction at every step of Emergency medicines growth. We seek growth through strength and patience. Negotiate based on merits. We will always be the ones who want to do it in the middle of the night so we should have credentials to do it at all times. 

    • Rapid Sequence Intubation 

    • Ultrasound 

    • Regional Anesthesia  

  • We are the safety net.  We must always be more than triage.

  • Threats to Emergency Medicine

    • Workforce issues with a large creation of residencies at non-university based programs and corporate involvement.

  • What we must do 

    • Differentiate the product

      • We have to have a continually evolving curriculum that is growing and expanding

      • Differentiate your career

    • Improve the value of care delivered

      • Examine variability

        • Metrics for admissions, CT utilization and consults are essential to understand. We must ensure we are doing everything to control our parts of the problems 

      • Reduce use when appropriate 

PROFESSIONALISM WITH DR. MCDONOUGH

  • How can we be better professionals, better leaders?  Professionalism is a belief system in which its members are trustworthy and respectful, not just about ethics but also about scientific and technical competency. 

  • In more simple terms Professionalism is about Trust. Trust offered by colleagues, patients, and the community. 

  • Examples of unprofessional behavior: 

    • Persistently incomplete medical records 

    • Being late, missing deadlines

    • Poor interpersonal communication/conflict, bad attitude 

    • Poor ability to accept performance feedback 

  • Being on time and appropriate sign-out (i.e. procedures, new patients) is dependent on group culture. Decide amongst your team what is acceptable and stick to it. 

  • Patterns of behavior are more telling than one-offs; we’re all human. 

  • Most unprofessional behavior comes from misunderstanding another's perspective; seek first to understand.  When a mistake is made, own it and strive to be better the next time. 

  • In summary, ask yourself, “Am I doing the right thing?”

  • Institutionally this is important as the ACGME has 3 milestones that look at Professionalism

  • Examples of Professional

  • General:Arrive on time, ready to go, well rested, and mentally present. 

  • Signout: be prepared, organized, reliable and strive for a tight signout 

  • Documentation: important for good patient care, organization, and personal well being

  • Off service: Know the culture, do not lower standards, best effort, reflect the department well, show up ready to be the hardest worker on the team

  • Grand rounds: Be on time, pay attention, be respectful, stay off social media or amazon, as a lecturer be on time, look the part, be respectful. 

  • Social Media: never come close to violating patient privacy, posts are permanent, don't be an idiot, don't post anything you wouldn't want your boss or parent to see

Discharge, Transfer, Admit with Dr. Paulsen

Disposition Decisions:

  • Where do patients need to go? They can admitted, discharged, or transferred (ED to ED, ED to Inpatient, ED to OR, ED to ICU, ED to IR/Cath lab).

  • Transport and how they get there is still up to you as the sending provider 

  • Patient Factors: access to follow up, ability to obtain prescriptions, functional independence, ability to care for self, family support

The 5Cs of Consultation -> https://www.sciencedirect.com/science/article/pii/S0736467915004904 

  • Contact

  • Communicate 

  • Core question

  • Collaborate 

  • Close the loop 

Case 1 Immune Thrombocytopenia (ITP)

  • Is the patient symptomatic and if so is it major or minor. If minor look at Plt count.

    • >20k observation or discharge and needs to see hematology in 1-3 days

    • Platelet count of 10-20k  Admit if new diagnosis with steroids or IVIG

    • <10 admit for treatment 

Case 2  Flexor Tendon Injury

  • Tendon Injury 

    • Examine each joint in isolation

    • Active and Passive ROM

    • Wound position at rest and at position of injury 

    • Communicate 

      • Dominate hand 

      • Occupation 

      • Zone of injury 

    • Management

      • Doing less is ok

        • Clean well

        • Close skin wound 

        • Splint to avoid tensions on the site of injury

        • +/- antibiotics

        • Follow up in 1 week 

Case 3 Acute Lower GI bleed

Case 4 Afib with RVR 

  • New onset

    • Unstable -> shock 

    • Stable -> treat the cause, rate control, rhythm control, wait and see

      • Wait and see - 9% with spontaneously resolve in the ED

      • Rhythm Control 

        • Ottawa Aggressive 

          • Procainamide 1000mg IV infusion or 17mg/kg over 60 minutes

          • If not successful electrical cardioversion

      • Rate control 

        • Medications

          • Metoprolol 

          • Diltiazem 

          • Digoxin

          • Amiodarone

        • Anticoagulation 

          • CHA₂DS₂-VASc and HAS-BLED score