Grand Rounds Recap 3.21.18
/
Year Directive (R1-R2): Residents as Teachers WITH DR. Ronan
Bedside ED Teaching
Set the stage by learning your student’s name and setting expectations. Specifically, ask what the student wants to work on. Pick an appropriate patient for the student to see and set expectations for how many minutes you would like the student to take in order to see and examine the patient. It is important to include the caveat that the student should come and find you if they are concerned that the patient is sick.
One Minute Preceptor Model
- Get a commitment
- Probe for supporting evidence/alternative explanations
- Teach ONE point
- Give positive feedback-what did the student do well?
- Give something to work on or look up
Ending A Shift
It is important to provide end-of-shift feedback. Sometimes it is difficult for students to identify when feedback is being given, so it is important to name it—“Let’s go over some feedback.” Start by asking the student how s/he felt about shift, what they did well and what they would like to work on going forward. Then address what it was that the student wanted in their expectation-setting at the beginning of the shift. Name specific behaviors- good ones to keep doing and a specific behavior to incorporate for next shift.
Year Directive (R3-R4): Life as an Academic Junior Faculty WITH DR. Hill, McDonough, Paulsen, and Stettler
Board Certification
Board certification is done through the American Board of Emergency Medicine (ABEM) and is classically taken the November after graduation although residents are board eligible for five years after graduating residency. After passing the qualifying exam (written boards) you then must take the oral examination. This occurs in either in the Spring or Fall following the qualifying exam. All single cases are given in the eOral style however triple patient encounters are still given in the traditional format. The oral exam is made up of five single patient encounters, lasting 15 minutes each, and two triple patient encounter, lasting 30 minutes each.
Maintenance of Certification (MOC)
There are multiple requirements, including life long learning self assessment (LLSA) tests, which are maintained through ABEM
Continuing Medical Education (CME)
Each state medical board has its own rules about how much CME is required for re-certification. It is important to know what each institution is JACHO certified for because this will often mandate topic specific CME for example, trauma, stroke, and cardiac.
Category 1 CME - Educational materials that have a purpose and have been certified. This can and will be audited.
Category 2 CME - Has a fairly broad definition. It includes any educational activity that relates to medicine or patient care that has not been designated for category 1 credit.
Staying Up On the Literature
Dr. Hill states that he uses evidence alerts as a resource to stay up on the literature.
Podcasts, consider those that just report on the primary literature. Beware of podcasts that put a lot of weight on the an individual's interpretation of the literature instead of reporting on the findings. FOAMed can also be a great resource.
Transitioning to Junior Faculty
How to establish yourself in academic practice. While establishing your path keep your options open in areas consistent with your niche. Mentorship is necessary and helpful in choosing opportunities. It is also good to establish goals that you want to accomplish for every 6 months, 1 year, and 2 years as junior faculty.
Operations: PE Response Team (PERT) WITH DR. Bennett, Fermann, and Hattemer
Pulmonary Embolism (PE)
Massive PE is defined as an acute PE with sustained hypotension, SBP <90mmHg, pulselessness, or bradycardia. Mortality in massive PE is 25-50% without intervention. AHA and ACEP recommend fibrinolytics in this patient population with a mortality number needed to treat of ten.
Submassive PE is defined as RV dysfunction, EKG changes, or troponin leak without hypotension. Catheter directed therapy (CDT) studied in SEATTLE II and PERFECT showed improved findings on ECHO but not necessarily improvement in patient mortality. For a more in-depth look at the submassive PE literature check out this podcast.
PERT
Made up of faculty from anesthesia critical care, interventional cardiology, interventional radiology, emergency medicine, trauma, MICU, and cardiac surgery. They would like to be called for all submassive and massive PEs regardless of how you are treating in the ED. The PERT protocol can be seen in the image to the left or found here.
Pharmacy Updates: Drug Shortages with Madeline Foertsch and Jessica Winter
Drug shortages
Manufacturing is the biggest known cause of drug shortages. Currently there are many, many drugs listed on shortage.
Opioid and analgesia shortage effects mostly IV opioids. The reason for this is multi factorial, it is partially due to manufacturing delays, increased demand, and DEA mandated decrease in opioid production. Alternatives to consider are oral opioids.
R1 Clinical Diagnostics: EKG Toxicology WITH DR. Li
See Dr. Li's EKG Tox primer here
Digoxin Toxicity
Digoxin affects the sodium-potassium pump. Digoxin toxicity causes a variety of EKG changes including AV block, changes consistent with hyperkalemia, and many other dysrrhythmias. Treatment of toxicity is usually 10 vials of digibind pending dig level.
Na Channel Blockade
Na channel blockage commonly presents with QRS >100ms in lead II, terminal R wave in lead avR greater than 3mm, and sinus tachycardia. Treatment sodium bicarbonate 2-3mEq/kg up to 150mEq IV for QRS narrowing. Interlipid can be used if the drug is lipophilic.
Lithium
Therapeutic levels cause T wave depressions and sinus node dysfunction. Toxic levels can cause a variety of EKG changes, ST changes, bradycardia, QTc prolongation, atrioventricular conduction delay, intraventricular conduction delay. Lithium level >1.5 mEq/L is considered toxic but treatment is typically based on level + clinical symptoms as chronic use can build level with relative tolerance. It is important to identify if the toxicity if acute or chronic, and many of the clinically significant patients requiring dialysis.
QT Prolongation
QT prolongation is caused by a myraid of medications. Risk factors of QT prolongation include age >65, myocardial hypertrophy, bradycardia, and electrolyte abnormalities. Treatment includes magnesium, repletion of potassium, and electricity if unstable.
CPC: Lecture Topic WITH DR. Golden
Phenytoin Toxicity
Phenytoin is a voltage gated sodium channel inhibitor. It is a highly protein bound drug, 90-95%. The IV formulation is rarely used due to the high risk of cardiac arrhythmias and hypotension. Adverse events related to oral phenytoin include agraunlocytosis and thrombocytopenia, gingival hyperplasia, ataxia, and hirsutism. As levels of phenytoin increase, patients develop nystagmus, ataxia, nausea, vomiting, slurred speech, lethargy and confusion.
Management
Chronic toxicity is generally managed with supportive care. Patients with acute toxicity can get dialysis but this is generally just in patients with significant underlying hepatic or renal dysfunction. More commonly, patients with acute toxicity are managed with supportive care.
R4 Case Follow-Up: Lecture Topic WITH DR. Gorder
NSTEMI
Acute coronary syndrome (ACS) but without an EKG showing ST elevation is considered non ST-elevation ACS, which includes unstable angina (UA) and non-ST elevation MI (NSTEMI). NSTEMI is differentiated from UA by the presence of elevated troponins.
NSTEMI Management
The evidence that looks at management and outcomes of patients with NSTEMI does not differentiate between the etiologies of NSTEMI.
For high risk patients there is increased benefit from anticoagulation and anti-platelet medications and early angiography and PCI. Studies have shown that patients have improved mortality and less ischemic events when placed on early anticoagulation and anti-platelet medication.
For all patients with NSTEMIs guidelines from the AHA and ESC recommends all patients should receive aspirin, plavix, and anti-thrombotics. Although guidelines recommend angiography and PCI for patients with NSTEMI the timing of when angiography should occur is debated.
Classification of NSTEMI
- Type 1 - primary coronary process due to acute plaque rupture
- Type 2 - state of reduced myocardial oxygen supple or increased demand without plaque rupture, sepsis most common cause in USA
- Type 3 - patients who present after cardiac arrest who do not have a pre-arrest MI
- Type 4 - post procedure
- Type 5 - post CABG
Type 2 NSTEMI
It can be very difficult to tell the difference between a type 1 and type 2 NSTEMI. In the ED these are often complex patients with significant CAD risk factors. Consider using TIMI score, GRACE score, or other risk stratification systems to delineate who needs additional diagnostics.
