Grand Rounds Recap 03.25.20
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Morbidity and Mortality WITH Dr. Kathryn Banning
Case 1 - Acute Cholecystitis
About 10% of patients with symptomatic cholelithiasis will go on to develop cholecystitis.
Risk factors for developing cholecystitis include increasing frequency of biliary colic, male gender, comorbidities, age > 48, and gallbladder size > 10x4cm.
Our acute care surgery colleagues have asked that we consult them in all cases of symptomatic cholelithiasis as it may be possible for them to add them on to their schedule sooner if there is space. This is especially important in the current conditions where all elective surgeries have been postponed or cancelled due to the COVID-19 pandemic.
Case 2 - Interventricular hemorrhage, Xa inhibitors, and andexanet alfa
Sometimes consultant recommendations are discordant with our treatment plan or judgement. Develop a strategy on how you plan to deal with that circumstance if and when it arises.
Our neurocritical care faculty recommend giving andexanet alfa as soon as possible in cases of potentially life-threatening ICH. It has a short half-life and may need to be re-dosed if the patient will be getting an invasive procedure such as an EVD, but in life or death situations we should do more.
Dosing of andexanet alfa is complicated. It’s probably best to have a reference material or consult your pharmacist.
DO NOT give andexanet alfa together with PCCs - this will greatly increase the thrombotic risk to the patient.
Our reversal protocols can all be found on Taming the SRU. For example, here is our protocol for rivaroxaban and apixaban.
Case 3 - Post-influenza pneumonia
Post-influenza pneumonias exist on a spectrum including primary viral, superimposed bacterial, and secondary bacterial. It’s difficult to predict how each strain will affect the public year-to-year.
Study have not shown any mortality benefit with empiric vancomycin, even in the presence of risk factors for MRSA. However, current IDSA guidelines recommend adding vancomycin to pediatric and critically-ill populations.
MRSA nasal swabs have an NPV of 96.5% and 94.8% for community-acquired and ventilator-associated MRSA pneumonia, respectively, and so may be a useful tool to limit vancomycin use in admitted patients with pneumonia. Go ahead and cover, but order the swabs too when you’re admitting someone for this.
In the early days of the COVID-19 pandemic are we seeing superimposed bacterial respiratory infections? It’s difficult to say because most of the information out there is still in the form of anecdotes and case reports. However, one paper from China suggested that up to 16% of patients may have secondary bacterial infections.
Case 4 - CBC in sepsis
Cognitive biases are the bane of our practice, and premature closure is one of the most common. Take care when admitting patients with labs that are still in process, especially when results of those labs may alter the management.
White blood cell count is overall a poor indicator of severe infection. 52% of patients with culture-proven bacterermia had normal WBC counts on their initial CBC.
Bandemia is present in up to 80% of culture-positive patients.
Anemia and thrombocytopenia can also be indicators of end-organ damage in sepsis and strongly correlate with mortality. Specifically, platelets are an important part of the immune response, and while they may be initially low, they should rebound to higher levels. Failure to do so has been correlated with up to 66% mortality.
Case 5 - Pulse pressure
If the pulse pressure is inappropriately narrow, have a low-threshold to obtain a repeat measurement before enacting any interventions. Narrow pulse pressure is defined as less than 25% of the systolic pressure. Aortic stenosis, cardiac tamponade, and hemorrhagic shock are examples.
Systolic blood pressure can be falsely reassuring, so you should also pay close attention to diastolic pressure and MAP, especially in critically ill patients.
Diastolic pressure is notorious for being falsely elevated, so if the pressure that you’re seeing on the monitor makes you feel skeptical then follow up on that instinct and recheck.
Widened pulse pressure is defined as difference greater than 100 and can be indicative of increased mortality in multiple disease processes.
Case 6 - Epidural abscess
Another common cognitive bias in emergency medicine is diagnostic momentum. This can come from multiple places, either our own biases or a patient or family member who strongly believes they have a particular pathology. One of the most difficult sources of inappropriate momentum comes from other providers who have incomplete or incorrect understanding of the true etiology and then confer that to us through their communication.
Epidural abscess is notoriously challenging to diagnose and easy to miss. Typical “red flags” have actually been shown to be poor predictors. Have a higher clinical suspicion in patients with indwelling lines, history of IVDA, or another site of infection.
Case 7 - Triaging the lobby
When overcrowding and ED boarding are at their peak, sick patients may end up sitting in the lobby and risk serious deterioration. They may even leave without being seen, in which case we may never know what happens to them.
Have a low-threshold to monitor the lobby to identify such patients, especially when beds are boarded.
Look for creative ways to care for those in the lobby and if you notice someone at serious risk (e.g. with grossly abnormal vitals, critical triage lab values, etc.) call attention to it and get them back ASAP.
Wellness Curriculum WITH Drs. Kelli Jarrell and Trevor Skrobut
For this installment of the wellness curriculum we are joined by our panel of experts, Drs. Steve Carleton, Sarah Continenza, Grace Lagasse, Jack Palmer, Robbie Paulsen, and Conal Roche, to talk about strategies they’ve developed over their years of practice to maintain their wellness and longevity.
For Dr. Roche - you’re known for your easy-going attitude and sense of humor. How do you stay so relaxed, especially on shift?
Have a good mindset coming into the shift - check your attitude and take a few deep breaths if you’re coming to work frustrated or angry.
On shift visualize someone you respect and try to emulate them.
“Fake it til you make it” - forcing strategies (e.g. forcing yourself to smile), although not Dr. Roche’s favorite, can also work.
A note from Dr. Paulsen - If you feel angry or frustrated, don’t bash yourself or try to suppress it - accept the feeling, deal with it, move on.
Remember that even the calmest people feel anger and frustration, but it’s how they respond that differentiates them.
For Dr. Palmer - how do you deal with stressors of work when you’re not at work?
Being a medical director during the pandemic is stressful.*
Don’t worry about the things you can’t control. Focus on what you can change and use the opportunity to become better, personally and professionally.
While at work focus on the things that you find fulfilling - for Dr. Palmer that means taking time to talk to patients and learn more about their lives and families apart from just the OPQRST of what brought them into the ED.
Lots of us suffer from being our own toughest critics - don’t mistake your own expectations of yourself for what others expect of you. Don’t be afraid or ashamed to protect the personal time you need to stay healthy.
*Editor’s note: while we all appreciate Dr. Palmer’s humility, speaking for his residents and colleagues, our faith in his leadership has never waivered and we’re all proud of the department’s response to the pandemic.
For Dr. Continenza - as an advocate of yoga, what techniques do you find useful on shift? Have you ever struck a yoga pose at work?
When you feel yourself getting frustrated, take a moment and think of two things that you’re grateful for.
Not as much in the ED, but yes - on off service rotations like ICU where there’s a call room Dr. Continenza has broken out into a yoga session from time to time. As a medical student she had an embarrassing moment of running into one of her attendings while using a stairwell for the same purpose.
For Dr. Paulsen - how do you optimize medical students’ and your own wellness on shift?
Communicate well - if you need to take time for yourself for something then be open and honest about it.
Set expectations and stick to them - whatever that may be, a 15 minute didactic, teach one thing about each patient, etc. It feels good to set a goal and accomplish it, but it’s easy to get frustrated when you feel pressure to accomplish something but don’t know what exactly.
Also, advocate for your students to be able to pick up patients when residents and APPs are fast and stalking the board.
Med students appreciate when their own role within the team is clearly delineated.
For Dr. Lagasse - How do you manage on-shift wellness?
Set specific goals for each shift. “Just be better” is both nebulous and huge, so small, achievable goals like “learn landmarks for this subclavian line” that are specific and targeted are much better.
This not only improves on-shift wellness, but also helps you become a better clinician.
For Dr. Carleton - how do you “keep your chin up” after a particularly difficult moment like a procedure that didn’t go well?
Failure on a given procedure or a shift isn’t a referendum on your worth as a clinician or a person, so don’t internalize or take it personally.
By the same token, you have to own your errors. This often can’t happen on shift because you need a mechanism to process, but that takes intentionality and time. Compartmentalizing will help you save the experience until you have time while getting through the rest of your shift.
Engage in “brutal” self-examination and think of what went wrong, why, and how you will prevent it from happening again, but focus your attention on the improvement rather than translating it to a character flaw.
Don’t hesitate to seek or accept help from other members of your team.
Accept that errors will occur. Even the people you respect the most have had procedures and patient encounters that went wrong.
To the panel - finding joy in your work is crucial to longevity. How do you continue to find joy in your work, even through frustration?
Dr. Carleton - we serve a necessary function in society that others do not wish to serve, and in that necessity lies satisfaction. We care for people that others don’t want to, and without judgement. Recognize the opportunity that you have to be a truly good person in helping individuals and society as a whole. Even on shifts that are mediocre in terms of efficiency or other metrics, remember that you have done good and righteous work.
Air Care Grand Rounds WITH Drs. Bill Hinckley, Amanda Humphries, and Mike Spigner
Aviation topic of the quarter - radio transmissions
Frequencies
Radios transmit over different frequencies that are grouped broadly into bands.
Air Care radios transmit at higher frequency bands (VHF and UHF)
Higher frequencies have shorter wavelengths and thus propagate over greater distances.
Types of propagation:
Line of sight - waves travel in a direct line from sender to receiver, requires a direct line of sight. This applies to FM radio, like our Air Care radios.
Ground wave propagation - lower frequency propagation, radio waves follow curvature of the earth and so can transmit beyond the horizon. Applies to AM radio.
Sky wave propagation - short wave transmission in which radio waves bounce between the earth’s surface and the ionosphere; allows for transmissions over vast distances.
Repeaters - to increase the distance of line of sight propagation, these are radio towers that serve as an intermediate point between a sender and receiver that are not themselves in direct line of sight.
Multi-Agency Radio Communication System (MARCS) - a system of repeaters set up through the state of Ohio that enhances telecommunications for public safety and first responders.
Encryption - Fire/EMS in this region are NOT encrypted, so remember no names or other PHI when communicating over the radio.
Air Care equipment specifics
We use two types of radios - Portable and mobile/base.
Mobile/base radio - relevant to us, these are located inside the aircraft. A few points about the controls:
Rockers and selectors - rockers are switches that turn on/off a particular channel for listening purposes; you can have multiple activated and listening at once. The selector chooses which channel you’re transmitting on, only one at a time.
Com1/2 = aviation communication
FM2 = contains all the channels over which we transmit to/from dispatch, EMS/fire for scenes, and the ER. In general, the selectors should ALWAYS be on this setting. If the selector is on this setting but you aren’t getting through to your intended party then check your frequency on the controls.
Vox = voice activation, sensitivity of the mic; clockwise = more sensitive.
Rx = received transmission; loudness of transmissions received from outside the aircraft.
ICS = loudness of transmissions from within the aircraft.
ISO/EMR = isolates the crew in the back from the front.
ICS CALL = notifies the pilot you need to talk when you’re isolated.
VOX/KEY = Toggles whether the mics in the aircraft are voice-activated or by button press.
PAT = turns patient headset on or off.
ICS box (cotter, carter, carver - who actually knows? - The thing you plug your helmet into.
Can be switched between voice activation (LOCK) and push-to-talk (MOM).
The clips are hard on the seatbelts, so try to avoid clipping them on there.
Portable radio
You can change channels and banks through the selector on top of the radio
Banks (ABC) all have the same channels, but bank C scans through all the channels and routes all traffic to you
If the knob gets twisted and you can’t hear or speak remember the mnemonic “to be or not to be” - the radio should in general always be set to Channel 2, bank B.
Radio etiquette
Golden rules
Clarity - there are multiple elements to this”
Speak slowly, enunciate, avoid abbreviations, use common terminology (e.g. affirmative, copy, out)
When you hit the key to transmit, wait for the “chirp” to know you’re connected before you speak
When calling out to another party, follow the convention “hey you, it’s me!” - if you’re flying in Air Care 1 you should say “base, this is AC1”
Begin and end each transmission with your call sign
Wait for an acknowledgement - “how copy?” “Lima charlie (loud and clear), go head”
Use the phonetic alphabet (alpha bravo charlie instead of A B C)
Give numerical values one number at a time: instead of “fifty” could be mistaken as “fifteen,” so instead say “five-zero” or “one-five” as examples.
Simplicity
Follow this script to keep the message short and to-the-point:
Unit calling, e.g. AC1
ETA, e.g five minutes out
Patient demographic, e.g. 55 yo male
mechanism/origin, e.g. scene MVC
Stability, e.g. give a complete set of vitals
Exam, e.g. a summary of only the most important parts (“head trauma” “abdominal bruising”)
Interventions, only if pertinent, e.g. giving blood
Requesting resources, e.g. requesting trauma stat
Bringing it together: “Base, this is Air Care 1. We’re five minutes out with a 55-year-old male, scene MVC. Current vitals are xyz. The patient is currently GCS 3 with head trauma and abdominal bruising. We’re giving blood and request a trauma stat activation.”
Pro-tip: faculty who receive these calls consistently say they want:
Complete set of vitals
Give your ETA twice! Sometimes they get distracted listening to the clinical details or may lose this in transmission.
Frame your transmission like a consult.
Brevity
Avoid rambling reports and synthesize info to convey relevant points.
Security
You’re on an unsecured channel so avoid names and PHI.
A note on the patient who is “as-billed”:
In general you should call report on EVERY patient regardless of destination, however this terminology is used for stable patients with known diagnosis, early flight docs should practice every call and avoid this phrasing
If you’re bringing a patient to the ED then you need to call a report every time, regardless of how long you’ve been flying. The ED needs to be aware.
