Grand Rounds Recap 4.11.18

/

Leadership Curriculum: Failure WITH DR. PALMER

  • We are in a career where many of us have achieved significant success professionally; failures or perceived failures can be difficult to process or deal with. However, all of us will experience failures in life. 
  • Sharing stories of failure can help us with owning the process. In this leadership curriculum activity, we broke into small groups and shared stores of personal and professional failure.

What does it mean to be vulnerable? 

  • Failure is commonly associated with emotions such as fear, defeat, anger, shame and vulnerability.
  • Vulnerability can be reframed as willingness to take an emotional risk and exposing yourself to uncertainty. Our work as physicians can exposure us to vulnerability just as much as relationships in our personal life can.
  • It is much easier to avoid vulnerability than to embrace it; anything that exposes us to the risk of failure or hurt can be considered a vulnerable position.
  • This, however, is likely a maladaptive response that comes from a place of shame. Other maladaptive responses include blame, anger, disconnection and lying. It's important to be able to recognize these reactions in real time and practice methods to get around them. 

How do we respond to failure?

  • After a failure, it's important to acknowledge what you're feeling and why. This avoids repressing emotions, which can lead to maladaptive responses. 
  • When you are processing a failure, you need to differentiate between what you're telling yourself about why you failed (self-protection) and what the actual truth is. There may be a significant gap between these two categories. 
  • Recognizing the above can lead to change and improvement. 

Why do we fail? 

  • Reasons suggested by the group include: not asking for help; not wanting to change; not having the needed skills; not being willing or able to put in the work required; inadequate understanding of the task; overconfidence or under-confidence; and self-criticism.
  • We are relying on the wrong type of motivation
    • There is a difference between intrinsic and extrinsic motivation
    • Everyone is motivated to a different degree upon a continuum of intrinsic and extrinsic factors
    • Intrinsic motivation includes doing things due to a sense of purpose or belonging, or mastering a craft
    • Extrinsic motivation includes doing things because of a fear of failure or punishment, or doing things for a reward
    • In the setting of a failure, looking back on your motivations can help you understand why you failed
  • We have the wrong mindset
    • Can view this as a "fixed versus growth mindset;" this concept comes from the education literature, which is pertinent to our field as we are lifelong learners
    • Those with a "fixed mindset" see their intelligence as fixed and finite; they get easily discouraged with challenges or failures, and are afraid of failure
    • Learners with a "growth mindset" see failures as an opportunity to learn more or do something differently, and are less afraid of failure
    • Everyone is on a continuum of these two mindsets; you can move yourself along this line towards growth via effort
    • How you interpret challenges and failures is a choice; if you are aware of your thoughts and emotions, you can respond to failure with a growth mindset
  • We need more grit
    • Grit is sustained passion and perseverance for the long term
    • To develop the growth mindset discussed above, it takes grit: you must develop your passions and cultivate your purpose 
    • While a fixed mindset would say that talent is innate and finite, a growth mindset would state that deliberate effort is required to transform innate talent into a true skill -- this is what gritty people do
  • We need to develop our deliberate practice
    • This involves things like setting goals, incorporating feedback, getting out of our comfort zone and using coaching methods
    • Deliberately practicing things we are not good at is a way to transform a fixed mindset to a growth mindset

EM/Peds Lecture: upper airway obstruction WITH DR. Ashish shah

Why do children develop stridor more frequently than adults?

  • It comes down to anatomy. They have disproportionately larger heads, a floppy epiglottis and a narrow subglottic space.
  • The smaller airway in children is disproportionately narrowed by edema when compared to the airway of an adult.

How do you examine and work up a child with stridor?

  • Think of three categories for patients with stridor: infectious, non-infectious and chronic
  • Chronic causes can include congenital things such as laryngo- or tracheomalacia, webs and rings, as well as children with a known ENT history
  • Non-infectious causes include foreign body, anaphylaxis, ingestions, burns and vocal cord dysfunction
  • Infectious causes include croup, epiglottitis, bacterial tracheitis and deep space infections
    • Most children with croup will do well and will go home; less than 1% of children with croup require an ICU stay
    • The incidence of epiglottitis in children has significantly decreased due to vaccination rates; this is now more common in adults, but still can occur in children
    • Bacterial tracheitis is more common in older children and is usually seen after several days of viral URI type symptoms
    • Deep space infections include RPA and PTA
  • How to differentiate between the above infectious etiologies?
    • Age: croup is more common in younger children while bacterial tracheitis is seen more in older children; RPAs are usually seen in children under the age of 8
    • Appearance: epiglottitis patients will look more ill upon presentation
    • Neck stiffness or refusal to extend their neck suggests RPA or another deep space infection
    • If you diagnose a child with croup and they return with persistent stridor, consider another etiology
  • Management
    • For croup: +/- soft tissue plan films of the neck ("steeple sign"), steroids, racemic epi, can consider heliox
    • For epiglottitis: soft tissue plain films of the neck ("thumbprint sign"), antibiotics 
    • For bacterial tracheitis: antibiotics
    • For deep space infections: soft tissue plain films of the neck +/- CT of the neck; antibiotics; possible surgical consult

R1 Clinical Knowledge: Occupational Exposure WITH DR. JENSEN

  • Occupational exposures require contact with a particular material, which can range from not infectious to possibly infectious to definitely infectious
    • Infectious exposures include blood, bloody fluids and genital fluids
    • Possibly infectious exposures include CSF, pleural fluid, peritoneal fluid and synovial fluid
    • Not infectious include urine and fecal matter
  • With regards to the route, it can include anything from intact skin to blood-to-blood contact
  • The most infectious diseases include HIV, Hep C, Hep B, as well as many other such as HSV, TB or VZV
  • Who's at risk? There are over 385,000 occupational exposures in the US annually
    • Nurses represent 33-50% of these
    • Doctors are around 7-14% of these exposures
    • Remainder of healthcare providers represent the rest
    • Those who work extended work hours (> 24 h) are at 1.6x the risk of exposure 
    • Teaching hospitals have 2x the incidence of occupational exposures
  • The inoculum is what matters most
    • For HIV, there is a 0.03% chance of exposure via mucous membrane and a 0.33% percutaneous risk; for Hep C, the percutaneous risk is 1.8%, with a rare chance of infection via the mucous membrane route
    • The risk of infection increases with the number of potential infectious particles to which the patient is exposed, which is a factor of the type of exposure (needle in a vessel, visible contamination with blood, etc.)
  • How do we manage this in the ED?
    • Clean the exposed area with soap and water
    • Attempt to get as much information on the source patient as possible, as well as the method/route of exposure
    • Get baseline labs on the patient as well as the source patient, if possible
    • Consider post-exposure HIV prophylaxis 
      • This should be done if the source patient is a known HIV positive patient or is a high risk source
      • PEP is given as soon as possible (within hours) but usually no more than 72 hours after exposure
      • Medications to start in the ED include Truvada (emtricitabine/tenofovir) as well as Isentress (raltegravir), and zofran
      • This should be given for 4 weeks or until the source patient can be tested and is negative
    • What about Hep C prophylaxis?
      • HCV is now essentially curable and it is more cost-effective to treat patients instead of given prophlyaxis
      • Additionally, you must know the genotype of HCV to give prophylaxis or treat appropriately; doing otherwise can open the patient up to resistance
    • Give counseling and establish follow up
      • Patients will require serial lab testing and follow up
      • Here, patients see Occupational Health within 72 hours

R4 Case Follow Up: Expedition medicine WITH DR. PLASH

  • When planning for an expedition trip, you must evaluate:
    • The environment (temperature, altitude, animals, etc.)
    • Disease local to the location
    • Medical facilities or resources available
    • Potential routes available for evacuation
    • How isolated the area is from the outside world?
    • Think of the people (patients?) who are going on the trip: what is their level of experience, what medical problems do they have, what medications do they take on a daily basis, etc.
  • What is your liability as a physician if you go on an expedition?
    • Expeditions can range from unpaid to paid, with some trips giving a discount to the physician who comes along
    • You must have separate malpractice insurance, which is usually separate from the expedition policy or waiver
    • You must have a medical license for the area of travel; depending on your role, you may be able to get a volunteer license 
    • You must know your responsibility/liability for the medications you are bringing or are responsible for
    • Consider your responsibility to and interaction with the locals, and be aware of Good Samaritan laws in the area to which you plan to travel if you go in a volunteer role
  • What will you do on the trip itself?
    • Although this depends on where you go, there is overall a low likelihood of needing to provide major care (<1%)
    • You may see a high rate of minor complaints, ranging from GI discomfort to sprains and strains, depending on the type of trip or expedition 
    • You must maintain records and documentation of patients you take care of while on the trip, and these records must remain confidential
    • As the trip progresses, continually reassess the patients and know when to call for help/cancel the trip