Grand Rounds Recap 1.19.22
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LEADERSHIP CURRICULUM: GROWING FROM FAILURE WITH DR. ROBBIE PAULSEN
Starting with the Right Mindset
Despite the common assumption that praise for ability has beneficial effects on motivation, multiple studies suggest that praise for intelligence negatively affects motivation for achievement when compared to praise for effort.
Fixed Mindset–characteristically supports the idea that intelligence is given and if you have the ability you don’t need effort. For those with this mindset, It is important to look smart at all times and at any cost. They often choose easier tasks that display their ability favorably.
Growth Mindset–believe intelligence is developed and that effort activates ability. People with this mindset focus on learning at all times and at all costs, and believe in the power of “yet”. They are willing to risk not looking good/failing for the sake of learning.
In medical education, there is initial emphasis on a fixed mindset (UME) due to the necessity of good grades and transitions to more of a growth mindset (GME). This leads to defensive behavior and risk aversion, and focus on 959+ performance goals instead of learning goals during early residency.
In the event of a “failure”, people often feel threatened and tune out until it cannot be safely ignored. This is “aversion learning” – everyday failures that don’t have much consequence may not lead to learning.
Brené Brown’s Philosophy On Coping With and Learning from Failure
The Reckoning–acknowledge what is happening/has happened and that you are feeling something.
The Rumble–explore why you are feeling what you are feeling and then write your ‘crummy first draft’ of what happened. This can be self-deprecating, avoidant, and full of excuses but should ultimately grow into an insightful reflection of what led to failure, what you need to know about yourself and about others, and what you can learn from it. This step is about exploring boundaries, shame, blame, resentment, forgiveness as you reflect, reality-check and challenge the failure in order to define ways to learn from this experience. This work culminates in a summary of what happened, ideas on why it happened. and what steps can be taken into the future to prevent repeat occurrences.
Common feelings experienced during The Rumble:
Guilt vs Shame: Shame is an indictment of ourselves and our existence whereas guilt is a focus on specific behaviors or actions. Guilt gets a bad reputation but it can be a powerful and healthy motivator for change.
Accountability vs Blame: Blame serves as a quick and easy way to off-load anger but does not motivate change and can drastically impact relationships and team dynamics. Accountability is motivated by wanting to live in alignment with our values, where we hold ourselves/others responsible for specific actions and their specific consequences.
Responding to Failure in Real Time
Take a self-compassion break
Separate your sense of self from your behavior
Treat yourself like you would treat a friend who is in the same situation
Praise processing, praise the process
Set approach goals (i.e. achieving a positive outcome), not avoidance goals (i.e. avoiding an adverse outcome)
Share a struggle on each shift
QI/KT: CONTRAST EXTRAVASATION WITH DRS. JUSTINE MILLIGAN AND MARLENA WOSISKI-KUHN
Extravasation → tissue edema → venous congestion and ischemia → necrosis → capillary leak → further edema and congestion.
How does extravasation happen?
Back-walling the vein when the IV is inserted
Catheter dislodgment from the vessel
Erosion of the vessel by the catheter
Occlusion of the vein leads to elevation of intravascular pressure during infusion which ruptures the vessel.
Vessel rupture due to thrombophlebitis from irritating infusions
Types of injury from extravasation
Local inflammation
Skin necrosis and ulceration
Compartment syndrome
Risk factors for extravasation events
Power injectors
The utilization of power injectors (standard in modern CTs) has a 2-3x higher rate of extravasation events when compared to manual injections of contrast. This is thought to be due to the fact that the machine pushes contrast at a faster rate than manual infusions, and there is no-one immediately at bedside to monitor the IV as the contrast is actively being pushed.
Age
Extravasation is more common in older patients, which may be related to the fragility of their vessels
Sex
Studies have also shown that females are more likely to suffer from contrast extravasation, even when controlled for comorbidities and age. This is thought to be related to the fact that females have more subcutaneous tissue which may predispose IVs to dislodging, and the fact that women lose collagen at a faster rate with age than men.
Location
The hand and forearm have a higher rate of extravasation than IVs that are in the antecubital fossa. Additionally, contrast extravasation is typically less well tolerated in the wrist and forearm than in the AC fossa.
Placement
Ultrasound guided IVs have been shown to have a higher rate of contrast extravasation when compared to IVs placed without ultrasound assistance.
Recognition
Most Power injectors have a machine that monitors pressures in the IV as contrast is injected, CT technicians monitor this pressure for spikes which may indicate extravasation. These machines will frequently tell you how much contrast has been infused at the time of elevated pressures as well.
The patient will typically report pain and swelling immediately
If there is a question of whether extravasation occurred, you can obtain a plain film, as the contrast will show on the x-ray.
Severity of Extravasation injuries
Mild - mild redness, swelling, pain
Moderate - blistering, induration, partial thickness skin ulceration
Severe - necrosis, full thickness skin ulceration, non-compressible swelling, neurovascular compromise, compartment syndrome
Timeline of injury
Immediate - Pain and swelling
2-4 hours - Blistering and compartment syndrome
6 hours - Ideal deadline for surgical management
24-48 hours - Peak of acute local inflammation
Hours to days - Tissue necrosis
Initial Steps
Expose the entire extremity
Remove the IV
Look for erythema, edema, blistering, tenderness, induration, temperature, pulses, motor, strength, capillary refill.
Outline the edema and erythema.
Document with time of initial exam and location of the IV. Be sure to include pictures with Haiku.
Management
Elevate the affected extremity - this promotes fluid reabsorption
Ice or heat?
Ice! - In randomized control trials, cold compresses have been shown to significantly reduce skin ulceration. Warmth reduced extravasate volume but did not affect induration or pain (Elam et al 1991, Hastings-Tolsma et al 1993)
We recommend applying ice for 20 minute increments with 20 minute breaks.
When to consult hand surgery:
Progressive pain or swelling
Skin ulceration or blistering
Neurovascular compromise
Concern for compartment syndrome
Invasive management options by hand surgery
Stab incisions can be made under local anesthesia which allow the extravasate to be aspirated, the tissue irrigated, and drains to be placed
Squeeze Evacuation - Multiple slit incisions are made into the affected area and then the contrast is milked out. The extremity is left open to drain.
Fasciotomies - may be necessary especially when extravasation occurs from deeper vessels.
R3 TAMING THE SRU: CARBON MONOXIDE POISONING WITH DR. CALYN CRAWFORD
The Case:
A patient was brought in by EMS after being found in his car, which was not running, at his job that morning around 1000. He was last seen well at 2100 the day before. EMS found him somnolent but protecting his airway, hypothermic to ~90 degrees, normotensive, normocardic, and mildly tachypneic, with a fingerstick glucose reading ‘>500’. On arrival at the ED the patient was still somnolent with some gagging and coughing. He had dried emesis around his mouth and nose, his skin was cold and dry, and he would moan to sternal rub and withdrawal to painful stimuli. His EKG showed sinus tachycardia without obvious signs of ischemia or dysrhythmia. His stat blood gas returned with a pH of 7.2, CO2 of 56, HCO3 of 22, and a carboxyhemoglobin of 43.2. He had a negative CTH and negative CXR.
Carbon Monoxide Poisoning
Pathophysiology
Carbon monoxide is a tasteless, odorless, colorless gas.
It binds to hemoglobin with an affinity 200-250x that of oxygen, causing oxygen to be displaced from hemoglobin, resulting in tissue hypoxia.
Exposures occur through house fires, gas-powered electrical generators, automobile exhaust, cigarette smoke, camp stoves, boat exhaust, and heaters.
Presentation
Symptoms present within 2 hours of exposure and can include headache, dizziness, nausea, vomiting, chest pain, fatigue, syncope, and cherry red skin.
Notably, to achieve cherry red skin you need a lethal dose of CO, and so this finding is rarely seen clinically.
Treatment
The half-life of CO on room air is 240-360 minutes, but only 80 minutes in the setting of 100% Fi02, so oxygen supplementation is the mainstay of therapy.
Hyperbarics - increases the pressure around the patient which causes displacement of carbon monoxide from the tissues and shortens the half-life further. Indications for hyperbarics include:
Carbon monoxide levels > 25%
Carbon monoxide levels > 20% in a pregnant woman
Patients with an altered level of consciousness
Patients with signs of end organ damage.
Be sure that patients suitable for discharge have a safe environment that is free from carbon monoxide exposure to return to
SIMULATION-INFORMED DESIGN WITH VISITING LECTURERS DRS. CHRIS HICKS AND ANDREW PETROSONIAK
Crash testing - Trialing simulations in the actual setting that you practice in to find flaws so that they can be corrected for real patients. In the same capacity that cars are thoroughly crash tested before the model is released onto the road, healthcare environments should also undergo a ‘crash testing’.
The goal of ‘crash-testing’ is to fuel a cycle of “Design → Build → Train”
Current State Analysis
Assess your current state by testing your department, as-is, in simulations. This will demonstrate the functionality, but also highlight any flaws that you may not have otherwise noticed.
After obtaining data from a simulation, you should debrief with the team that was part of the simulation. From this you get data which falls into two broad categories:
Known knowns - The things that everyone knows are inefficient and that everyone gripes about, but never get changed.
Unknown unknowns - The things that no-one has ever noticed or even considered might be a problem
Once you know the known-knowns and the unknown-unknowns, you can ideate and innovate to solve the problems
You then trial these new innovations in simulations to see if they succeed or fail, and find a new set of known-knowns and unknown-unknowns. You repeat this cycle over and over again to continually optimize your department.
Future State analysis
Performing a premortem using prospective hindsight
Prospective hindsight is a technique in which you imagine the hospital or emergency department has failed in response to a certain stressor (an international pandemic, a mass casualty event, etc). You imagine the certainty of failure in response to the event and palace yourself in that moment of failure. You then perform a pre-mortem examination of the system, working backwards from the point of failure to determine what led you there. Some questions you may ask in this process include:
What went wrong?
Where are we weakest?
Were there warning signs and if so what were they? Why did we miss them?
What protective measures failed and why?
From this process you identify weak points and build support around them ahead of catastrophic events.
