Grand Rounds Recap 2.12.20

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Leadership Curriculum: How to Promote Yourself WITH Dr. Palmer

Many think that if you put your head down, do the work and you will be rewarded. There is some truth to this, but you can’t rely on this alone. Several faculty can provide many examples where this does not 100% apply. While uncomfortable, there is skill and value in promoting oneself.

This is particularly among women. In a Harvard Business study, 40% of MBA students are women, 50% are in the workforce. However only 15% in senior leadership, 3% CEOs. Importantly this has nothing to do with being a mom or starting a family, as there was no difference in salary or rank when comparing the two groups.

Why do women not promote themselves as much as men? There is a gender gap in self promotion. Self promoters have higher rates of promotions, new jobs, bonuses, pay raise. One study showed that men rank themselves 33% higher than equally performing women. Why does this occur? Some of the hypotheses include confidence differences, strategic incentives or gender differences in backlash. Turns out gap held up despite controlling for these hypothesized explanations.

So how do we promote ourselves?

First things first …

  • You MUST build your career first to be considered for promotions. You will not be respected unless you are a good physician. We are doctors first. Get great at medicine first.

  • Find your why - Why did you want to be a doctor? Why did you go into EM?

  • What do you want in life? In work? In relationships?

Add value: Are you adding value to your group?

  • Good to know what your group values. What do you bring to the table that aligns with the values of your group?

  • Must be honest about what you bring to the table

  • “Get better before you get ahead”

Talk about Yourself

  • When you or your team has successes, talk about it!

  • Why? When you succeed, your team and your boss succeed. You are talking about the work, not yourself.

  • When? Use semi-annual/annual reviews to make sure your boss knows your successes as well as your goals and ambitions. Find ways to work successes into conversations at the right time

  • How? There are good and bad ways to talk about.

    • Pick the right moments

    • Stories go a long way! Be prepared, know your story and tell it.

    • Grandstanding and bragging is a no, humility is KEY!

    • Ensure you are talking about your team first, give credit.

    • Don’t be bashful. “Aw shucks” doesn’t cut it.

    • Have tact, but get your successes out to more than just your boss

Get out there!

  • You need to be more visible within your group or company

    • Speak up at meetings

    • Get your results out there in a newsletter or update

    • Give lectures at grand rounds

  • Social media - important, but BEWARE!

  • Also consider external opportunities; publications, panels, speaking events

Networking

  • Easier said than done

  • Be Proactive! Get out of your comfort zone

  • Ask questions and learn about people - listen to them

  • Give, do not get. Have intentions to find out how you can give to others so you know where your skillsets may be valued.

  • Relationships take time

Mentorship, Advocates, Sponsors

  • Women and multicultural professionals receive less sponsorship than caucasian men. 2010 study showed more women are assigned mentors, yet 15% more men receive promotions

  • MENTORSHIP

    • Sometimes assigned, generally mutually selected

    • Allow for passage of knowledge, experience, support, advice

    • Help you develop a skill or set of skills

    • Personally mutually beneficial

    • Safe space for discussions, vulnerabilities, failures, etc.

  • ADVOCATES

    • Bridge the gap between mentors and sponsors

    • Has a direct relationship with you and your work

    • Speaks positively about you and your work to others

    • Members of your network’s inner circle. Gives credit for your work, great references, believe your ability

  • SPONSORSHIP

    • Senior level personnel

    • Internal (usually)

    • Typically not “asked” to sponsor, sponsor chooses a “protege”. Advocates can promote this.

    • Champion the protege’s visibility, expands their network

    • Controls or influences decision making towards your advancement

    • Professional mutually beneficial - IF you pan out

Wrapping Up

  • The old way doesn’t cut it anymore

  • More difficult for women to get ahead

  • Get GREAT at your job first

  • Talk about yourself. Humble but not passive, give yourself credit.

  • Get yourself out there

  • Find mentors, build advocates and earn sponsors

Leadership Curriculum: the curriculum vitae - a tool for the trade WITH dr. Mcdonough

Curriculum vitae, a latin phrase that means “course of life”. Your CV should be a promotional tool. This should be a chronicle of the events of your academic life - this is not a resume. It must be tuned to the audience and position desired.

Important Points

  • Make it look nice

    • Consistent formatting, easy to read

    • Use non serif font as it is easier to read

  • Specific headings will vary (please see below)

    • Highlight your achievement; don’t put most important stuff at the bottom

    • Target to your audience and job

  • Should be complete but not indulgent

    • When starting out it is ok to include medical school and may include undergrad, but as you move on in your career you will gradually take certain things off

  • Explain things an outsider would not know

    • Don’t use institution specific acronyms without a brief explanation

  • What is the end goal? Consider what your audience values

    • Academic vs community vs fellowship

    • They want to know that you will be involved and rooted

Section Headings

  • Contact information: Should be at the top, make it eye pleasing and easy to find

  • Education and training: generally next section in reverse chronologic order (ex. residency first, then medical school)

  • Academic appointments: use terms “clinical instructor” - this can be important in the way you will be promoted

  • Clinical experience: include all sites where you have worked as well as statistics

  • What else? What is your goal? Ex. Research (include grants, publications, presentations), leadership, teaching (include lectures - can make hyperlink), mentoring

  • Professional activities: include committee involvement

  • Community service

  • Honors and awards

Other points …

  • Add detail

  • Be thorough

  • Use consistent chronology

EMS Grand rounds: Stroke and EMS WITH Dr. forde

 In the recent years, a lot of effort has been made for recognizing strokes by lay people in order to get patients to definitive care faster. After all, time is brain. Primary stroke centers were at 15 in 2005, but grew considerably to 800 by 2011. In 2012, additional requirements were need to be considered a comprehensive stroke center.

Current Certifications

  • Acute Stroke Ready Hospital (ASRH): basic care with tPA, “drip and ship”

  • Primary Stroke Center (PSC): standard stroke care, vascular imaging, stroke inpatient care

  • Comprehensive Stroke Center (CSC): neuro ICU, all capabilities 24/7, stroke research

  • Thrombectomy-Capable Stroke Center (TSC): PSC + thrombectomy and post-procedure care

Prehospital Stroke Care Considerations

When creating algorithms and screening tools for EMS personnel there are many considerations that come into play include screening, pre-hospital identification of LVO, provider education/training, transport times and destination, system integration, avoiding delays and transfer. Other considerations include education/training, reliability, time consumption and limitations.

So how accurate are EMS estimates of last known normal? A study in 2014, showed that there was less than a 15 min delta in the last known normal between EMS and neurologists in 91% of the cohort. Harder to identify in wake up strokes and older patients.

Screening and Triage Tools

Rapid Arterial Occlusion Evaluation (RACE)

  • Score > or equal to 5 indicated LVO

  • Sensitivity 85%, specificity 69%

  • 1 hour of training, then 4 sessions during first year making it very time consuming

Los Angeles Motor Scale (LAMS)

  • Components: facial droop 0-1 (absent or present), arm drift 0-2 (absent, drift, falls rapidly), grip strength 0-2 (normal, weak, none)

  • Initially stroke severity scar, then used score > or equal to 4 to indicate LVO

  • Sensitivity 81%, specificity 89%

Vision Aphasia Neglect (VAN)

  • Arm weakness plus one of the following (vision, aphasia, neglect) = positive

  • 2 hour training for RNs

  • 100% sensitivity, 90% specificity but small sample size (n=62)

Cincinnati Prehospital Stroke Scale

  • Facial palsy, arm weakness, speech (Y or N)

  • Any yes = positive with 72% probability of stroke

  • Simple to use

  • Created for stroke screening, not to detect LVO

  • Crowe et. al in 2020 compared all the above scoring tools and found highest sensitivity (69%) and specificity (78%) for CPSS

Transport

When should EMS bypass PSC and ARSH? The goal is to minimize delays and transfers and bring the right patient to the right place in the right time frame. Southwest Ohio Protocols state that if patient is C-STAT/LVO positive and LKN is less than 4 hours patient should go directly to CSC or TSC. The patient should be transported to CSC if C-STAT/LVO is negative, CSC or TSC is greater than 15 min farther away then the closest PSC. However, if the patient needs immediate resuscitation they should go to the nearest hospital. The bottom line is, delays often prevent patients from receiving maximum benefits and pre-hospital triage tools are limited.

Mobile Stroke Unit (MSU)

Essentially mix of ambulance and ED level of care with the capability to diagnose and treat stroke in the field. The goals include decrease time to thrombolytics, increase number of patients receiving tPA within 1 hour from symptom onset, decrease nee for patient transfers to higher level of care, increase system efficiency for stroke care, maintain patient safety and avoid increasing risk of adverse events. In urban areas, one study showed that MSU decreased time to thrombolytics by about 30 min. ASA policy statement in 2019 update regarding MSU showed 31% of subjects were treated with tPA within the “golden hour” compared with 4.9% in routine care. There is still ongoing research looking at patient outcomes.

Capabilities

  • CT/CTA (some include the aortic arch)

  • Meds and Equipment include: tPA, anti-hypertensives, RSI/Airway management, ACLS, +/- reversal agents to anti-coagulation

Complications

  • Hemorrhagic conversion in 2-7% and dependent on risk factors and stroke severity

  • Some concern about rarer complications, such as tPA induced angioedema, which would be more difficult to manage in an ambulance compared to ED

  • Have the additional capabilities to deal with ICH, airway management, BP management, seizure, anaphylaxis

Dispatch

  • Mostly in urban environments

  • Most often co-dispatch with EMS

Additional considerations

  • Patient size could be a limiting factor

  • CT must be able to lay flat to function which could be difficult based on terrain

  • How are we going to document, communicate and bill?

Uc EMS MSU GEneral operations

  • 7a-7p, 7 days/week

  • Dispatched by the County

  • Once the patient is in the MSU, the MSU team will care for the patient and transport the patient regardless of condition/diagnosis

  • The patient will be transported to the nearest appropriate hospital

pEM LECTURE: Pediatric Heme-onc emergencies WITH Dr. krack

Case 1

A 10 year old girl presents to community hospital with lethargy. 2 months of malaise, fatigue. She is noted to be tachycardic and pale on exam with scattered lower extremity petechiae. Work up notable for hyperleukocytosis and thrombocytopenia. Diagnosis is acute leukemia. Management included securing airway, starting aggressive hydration, heme-onc consult for leukopharesis.

Hyperleukocytosis

  • Diagnosed as WBC >100,000

  • Present at the time of diagnosis in:

    • ~10% of cases of ALL

    • ~5-20% of AML

    • All CML

  • Concomitant mediastinal mass is common - consider getting a CXR

  • Increased risk of early death

  • Can involve any organ system:

    • CVA: thrombotic or hemorrhagic

    • Pericardial hemorrhages

    • Pulmonary: hypoxia, pulmonary hemorrhage, respiratory failure

    • Renal failure

    • GI bleed

    • Splenic rupture

    • DIC

    • Tumor Lysis Syndrome

  • Goal: cytoreduction (decrease viscosity)

    • Leukopharesis and exchange transfusion may be considered

      • Any patient who is symptomatic from suspected leukostasis syndrome

      • asymptomatic patients: suspected AML with WBC >100K, suspected ALL with WBC >200K, suspected CML with WBC >200K

    • immediately begin hyper-hydration (2-3x maintenance) with non-K containing IVF

    • AVOID PRBC transfusions! Markedly increase whole blood viscosity. If necessary, transfuse with a ceiling Hgb of 8-9

    • May transfuse platelets liberally if <25K; correct coagulopathies

  • Treat tumor lysis syndrome

Case 2

A 4 year old male presents with a rash. Mother first noticed a spot on her lip today, and patient has been having spontaneous episodes of epistaxis at night. Had a “cold” two weeks ago. Vitals stable. Exam notable for scattered purport on lower lip with streaking of blood in the posterior pharynx. Work up notable for platelets of 2. Rest of blood work normal. Diagnosis is immune thrombocytopenia, previously known as idiopathic thrombocytopenia purpura. Management includes admission to hematology for consideration of IVIG. 

Immune thrombocytopenia

  • Abrupt onset of bleeding/bruising with antecedent illness/vaccination

  • Diagnosis of exclusion

  • Over 80% of patients present with platelets less than 20K. This is usually isolated abnormality in CBC, but 15% can have associated anemia.

  • Stratification for risk of serious bleed/ICH with absolute platelet count with platelet count less than 20K the greatest risk

  • Bleeding is the guide to treatment:

    • Suspected ICH

    • known ITP with significant trauma

    • recurrent/unabating mucosal bleeding

    • anemia secondary to blood loss

    • extent of petechiae/purpura NOT a reason to treat

  • Bone marrow transplant not necessary in kids >12 mo with typical features

  • Treatment:

    • Adjuvant therapies: nasal packing, phenylephrine (epistaxis), hormonal therapy (menorrhagia)

    • Significant bleed: TXA, platelets, possible splenectomy

    • First line: IVIG or steroids; Second line: Rituxomab and thrombopoeitin receptor agonists

    • AVOID STEROIDS if still undifferentiated (giving steroids in all cases can delay diagnosis and worsen long term outcomes)

  • Dispo: most can be managed outpatient

    • Consider chronologic/developmental age of patient, parent comfort, distance from hospital

    • If platelet count <50K, would consult heme prior to discharge; will likely admit if platelet count <30K

Case 3

A 12 year old presents previously healthy with 6 weeks of progressive cough. Was give steroids and azithromycin by PCP one week ago, but symptoms worsening. Has had 20 pound weight loss, now unable to lay flat at night. Vitals notable for fever, mild tachycardia/hypotension. Exam notable for JVD and plethora of the face. There is a firm right supraclavicular lymph node and bilateral inguinal lymph nodes, as well as hepatosplenomegaly. CXR shows ill-defined mass. Diagnosis is Hodgkin’s lymphoma with mediastinal mass.

Mediastinal Mass

  • Potential to create life-threatening compromise of the airway or cardiovascular system

  • Superior mediastinal syndrome (SMS): compression of the trachea or mainstream bronchi by a mediastinal mass

  • Superior vena caval syndrome (SVCS): compression or obstruction of the vena cava

  • May mimic respiratory illnesses

  • Patients may be asymptomatic or in extremis

  • Keep in position of comfort: degree of symptoms does not always correlate with the degree of airway compromise

  • Relative contraindications to sedation/anesthesia include orthopnea, upper body edema, dyspnea, impending respiratory failure, tracheal cross sectional area <50% of normal severe compression of both main stem bronchi, PEF ration <50%

  • Accurate diagnosis is critical … however imaging and tissue acquisition can be problematic. Avoid anything that will compromise

  • If minimal to no symptoms and no metabolic derangement, can discharge home with close oncology follow up