Grand Rounds Recap 7.5.23

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Manual vacuum aspiration with Drs. Yates and Hughes

  • Early pregnancy loss accounted for over 900,000 emergency department visits in 2021 alone, and there is concern with the changing legal landscape of safe medically provided abortions that this number will increase due to self-managed abortion complications. 

  • Manual Vacuum or Manual Uterine Aspirations are becoming standard of care in emergency departments across the country as a time/cost-effective and efficient alternative to expectant, medical, or surgical management

  • Protocol requires significant clinical bleeding and inevitable and incomplete abortion or concern for retained products of conception, and this definition and decision to move forward with procedure is made by gynecology in conjunction with the patient.

Community Corner: Abscesses WITH Dr. Sabedra

  • Specific abscesses to be aware of:

    • PTAs: Always need antibiotics + something else (incision or needle or observation)

    • Felon: Use a finger tourniquet and make a stab incision

    • Bartholin Gland Abscess: made up of vaginal mucosa, usually does not require antibiotics

    • Anorectal: only drain if small, visible, and close to the anus - otherwise consult colorectal surgery

    • Pilonidal cyst: ONLY drain if obviously infected, and give general surgery follow up

    • Hidradentis Suppurativa: I&D may promote recurrence, so only drain if one and small, and make sure patient has dermatology follow up for long-term medical management

  • Packing Pearls:

    • Use if abscess is 5cm or larger, for patients who are immunocompromised or have diabetes, and in those who feel capable of removing the packing

    • Note - don’t pack tightly, will not help with healing and will increase pain

    • For Bartholin gland abscesses - will often use a Word Catheter vs. Jacobi Ring for continued drainage

Effective Efficiency WITH Dr. Hughes

  • Pitfalls:

    • We are not multitasking, we are task switching

    • Instead of shotgun orders, do minimum workup for patients with a specific complaint

  • Goal is disposition in the emergency department, so “hit the box” does not just include seeing patients but also their documentation and disposition

  • On shift hacks:

    • Documentation - start note with sign up, dictate H&P immediately, pre-populate discharge instructions, document MDM or ED course before disposition, don’t document on patient’s who have left the ED

    • Communication - setting expectations up front with patients, don’t delegate communication of orders just to EHR, run board with nurses and other team members, relay intent and not orders to patients, round on patients

    • EHR - quick buttons for starting notes, notifications for pending results (limit the number so no alarm fatigue), favorite specific follow up physicians/clinics, use epic search function

  • Time Management: 

    • Using a value-based scheduling model to be efficient and effective in your time management

      • Be aware of how long something will take

      • Arrange your time appropriately for those tasks and set timers

      • Adapt your schedule to limit interruptions