Grand Rounds Recap 05.20.20

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Journal Club WITH Drs. Hughes, Shaw, and Walsh

Implicit Bias

  • Implicit bias is the unconscious attribution of particular qualities to a member of a certain social group.

  • The Implicit Association Test (IAT) was developed at Harvard to test for implicit associations between categories of things or people.

  • A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making, Dehon et. al.

    • Meta-analysis that sought to understand effects of implicit racial biases on physicians and their clinical decision making.

    • Found that physicians of different specialties have an implicit preference for white people over black, but this preference did not affect treatment.

    • Limitations of the study included use of subjective measurements such as case vignettes rather than quantitative measures.

  • Implicit Bias in Healthcare Professionals: a Systematic Review, Fitzgerald et. al.

    • Systematic review and meta-analysis seeking to discover if bias exists among healthcare providers for specific subsets of patients.

    • Concluded that bias does exist, and that it does exert an effect on clinical care.

    • Limitations of the study included heterogeneity and lack of methodological rigor in the primary literature included in the meta-analysis.

  • Review articles and meta-analyses: a methodologic intro

    • Review articles summarize the current state of understanding on a topic or survey and summarize previously published studies instead of recording new findings.

    • Typically the search methods used to find articles are not discussed and statistical summarization of results are often absent (especially in narrative reviews). Using the PRISMA criteria for reviews or criteria used in Scoping Reviews can circumvent these faults.

    • Systematic reviews and meta-analyses are not the same thing:

      • Systematic reviews collect and summarize available information.

      • Meta-analyses summarize information in statistical terms and require study homogeneity

QI Series: Leading Improvement WITH Dr. D. Thompson

Recap of previous session on 03.11.20

  • ACGME has emphasized the importance of quality improvement training in emergency medicine training.

  • As physician leaders we will be at the forefront of leading change.

  • Our curriculum includes many approaches to this training, including R2 QI/KT projects, monthly morbidity and mortality conferences, operations updates, and simulation.

  • Outcomes are predictable based on the parameters of any system. Medical errors are an example, and in order to address these errors we should examine our systems and their vulnerabilities.

  • PDSA cycles observe and measure how small changes affect a system in an effort to improve that system.

Closing gaps in healthcare

  • Perfect care may not be achievable, but we can compare our system to others in order to make improvements in multiple parameters including time to antibiotics, door to needle time, and sedation documentation, as examples.

Measurement

  • Measures can be classified as outcome, process, or balancing measures (balancing measures might include relationships between patient satisfaction and total ED visit time, for example).

Leading change at UCMC

  • Dr. Jack Palmer shared experiences in bringing quality improvement science to UCMC over the past ten years.

  • Care Delivery Integrating System (CDIS)

    • A structured approach to bring improvement measures in a measured, scientific manner.

    • The pilot project for CDIS in emergency services at UCMC involved developing a structured approach with common language and a scoring system for agitated patients, which was chosen because of the overlap of this population between the ED, OB triage, and psychiatric emergency services.

    • For resources on how to launch a quality improvement project and a structure to create lasting change:

      • Institute for Healthcare Improvement has free courses in quality improvement and patient safety. To register visit www.ihi.org.

      • Leading Change, by Dr. John Kotter, discusses best practices for leading change. Access at www.kotterinc.com.

Management strategies

  • Some management techniques include:

    • Public display

    • Identify standards

    • Pay for performance

    • Punishment

R1 Clinical Knowledge: Tick-Borne Illnesses WITH Dr. Crawford, R4 Mentor Dr. Gauger

Lyme disease

  • Caused by the gram negative spirochete, Borrelia burgdorferi

  • Transmitted by the black legged tick

  • Most common vector-borne disease in the United States at almost 300,000 cases per year

  • Cases tend to peak in summer and decline through the fall and winter.

  • Clinical phases

    • Early - a few days to one month after the bite; 60-80% develop the characteristic erythema migrans rash, and many can have systemic symptoms

    • Early disseminated - weeks to months after the bite; additional skin lesions, MSK Sx, neurologic Sx, cardiac Sx in up to 8% of patients

    • Late disease - chronic fluctuating arthritis, polyneuropathy, encephalopathy

  • Diagnosis

    • Early phase is made on clinical grounds - exposure with typical rash or symptoms

    • Serologic testing can be falsely negative if too early. Otherwise it should follow a two-tiered approach:

      • First test - enzyme immunoassay (EIA) or immunofluorescence assay (IFA)

      • Second test - IgM and IgG Western blot if Sx < 30 days; IgG Western blot only if Sx > 30 days.

  • Treatment

    • Doxycycline for most patients

    • Amoxicillin for children or pregnant patients

    • Cefuroxime is another option for children

Rocky Mountain Spotted Fever

  • Caused by gram negative coccobacillus Rickettsia rickettsii, transmitted by the American Dog Tick.

  • Most common in the southeast, but there are reported cases in Ohio.

  • Illness onsets usually 2-7 days after the bite with fever, headache, vomiting, joint pain; the typical petechial rash classically involves the palms and soles.

  • Complications include DIC, AKI, ARDS, skin and digital necrosis.

  • Diagnosis should be clinical, even before the rash is present; skin biopsies can be used for confirmation, but treatment should never be delayed.

  • Doxycycline is the treatment of choice; chloramphenicol is an alternative although not as good.

Babesiosis

  • Caused by Babesia microti, transmitted by the Black Legged Tick.

  • Symptoms are similar to malaria.

  • Diagnosis is made by blood smear with characteristic Maltese cross inclusions in erythrocytes or by PCR.

  • Treatment involves combination of quinine and clindamycin for 7-10 days.

Ehrlichiosis

  • Caused by Ehrlichia chafeensis, spread by the Lone Star Tick.

  • Symptoms are usually nonspecific flu-like illness.

  • Diagnosis is clinical and treatment is doxycycline.

Anaplasmosis

  • Caused by Anaplasma phagocytophilum, spread by the Black Legged Tick.

  • Flu-like symptoms for most, although older patients can become very sick.

  • Diagnosis is clinical and treatment is doxycycline.

Southern Tick Associated Rash Illness (STARI)

  • Clinically similar to Lyme disease and spread by the Lone Star Tick, but no microbiological pathogen has yet been identified.

  • Diagnosis is clinical and treatment is doxycycline.

R3 Taming the SRU: Refractory Ventricular Fibrillation WITH Dr. Modi

Management strategies

  • Double Sequential Defibrillation - only described in case reports, no high-quality data

  • Amiodarone and lidocaine - the bread-and-butter of v-fib management.

    • ALPS trial showed no difference in mortality or neurologic outcomes in all-comers but had a marginally higher rate of survival to discharge in witnessed OHCA.

  • ECMO

    • In a study out of the Minnesota School of Medicine, researchers found that patients who received bystander CPR and had short time to cannulation had better survival with favorable neurologic outcomes.

    • Low flow time has significant effects on survival and neurologic recovery.

    • Left ventricular wall thickness has been studied as a surrogate for ischemic injury. Hypothesis is that scar tissue formation from ischemia leads to LVH.

  • PCI

    • Shorter time to PCI leads to significantly better survival and neurologic outcome.

Delayed prognostication

  • Many patients will not show signs of neurologic recovery such as following commands until five days after cannulation.

  • Recovery is often complicated by infections such as pneumonia, delayed recovery of LVEF, and multi-system organ failure.

  • Takeaway is that things will likely get worse before they get better, and from a critical care standpoint they require a great deal of patience from providers.

The role of emergency medicine

  • eCPR cannulation has been shown to be successfully performed by emergency physicians, yet only 11% of academic institutions in the US actively incorporate EPs.

  • However, with the growing application of eCPR and the likelihood that field cannulation will become a reality in the US as it is in other countries, we are sure to have a growing role in the years to come.

Air Care Grand Rounds WITH Drs. Humphries, Spigner, Hinckley, and special guest Pilot Matt Johnson

Aviation Weather Decision Making

  • Pilots take a “funnel approach” to weather related decisions - start with the big picture and narrow down to the details to extract the truth from an imperfect forecast using multiple sources.

  • Visual flight rules

    • 3 miles visibility and 1000 foot ceilings are the minimum requirements for helicopter visual flight rules.

  • Instrument flight rules

    • When ceilings or visibilities do not allow for VFR, pilots can fly by instrument flight rules in constant communication with ground control to fly between predefined plotted points.

  • What can keep us from flying?

    • Thunderstorms. We can gain information on storms by using radar.

      • Radar

        • Base reflectivity and composite reflectivity are aspects of radar data that give clues to the severity of a weather front.

        • Radar can also offer information on rotational forces in a storm, which has important influence on decision to fly.

    • Icing

    • Fog

      • Important to understand that IFR is for low visibility at altitude, not for low visibility on the ground as created by foggy conditions.

  • Resources that our pilots use:

    • Aviationweather.org - big picture, outlook for the day. Also offers info for icing conditions.

    • Weathermeister.com - focused forecast for smaller area.

    • Weathertap.com - traditional radar, provides dynamic trends for weather in an area.

    • Beware reliance on weather apps for making decisions on whether or not to fly - information presented by most commercial apps is anywhere from 20 - 60 minutes old and therefore not accurate enough to make important decisions.

Air Care Simulation - Uncommon Procedures - See the videos here!

  • Nasotracheal intubation

    • Indicated for failure of oral intubation and as an alternative to cricothyrotomy with permitting anatomy and clinical circumstance.

    • Dependent on auditory feedback, which is very difficult in flight.

    • Prep

      • Decongest

      • Anesthetize

      • Lubricate

      • Dilate

      • Sedate

    • Insert

      • Start listening at 17cm

      • Glottic opening usually encountered at 19cm

      • Guide the tube anteriorly or posteriorly by flexing or extending the neck.

      • Endotrol tubes incorporate a trigger that allows for flexing the tube to a more acute angle.

      • If using a regular ETT you can insert to 18cm, inflate the balloon to raise the tip off of the posterior oropharynx, guide the tip through the cords, and then deflate the balloon to pass it through.

      • Alternatively, you can also place a regular ETT in ice water to force it to hold a greater curve to facilitate anterior positioning for easier passage through the cords.

      • Beck Airway Airflow Monitors (BAAM) is a device that fits on the end of the ETT and increases the volume of the sound as the tube passes over the cords.

  • Needle cricothyrotomy

    • Indicated for failure to intubate, failure to oxygenate a child less that 12 years of age.

    • 5 is the magic number

      • 5kg - less than, use the 18ga angiocath; greater than, use the 14ga

      • 5yrs - less than, connect the setup to the pediatric bag and bag as normal; greater than, use the transtracheal jet ventilation setup.

  • Cyanokit

    • Indicated for smoke inhalation in an enclosed space or industrial cyanide source AND altered mental status or hemodynamic instability

    • Administer as soon as possible.

    • Reconstitute with 200ml of NS and give 5g over 15 minutes, may repeat once.

  • Chest wall escharotomy

    • Prehospital indications include full thickness burns hindering respiratory mechanics such that there is an immediate threat to life; full-thickness burns hindering BVM ventilation in cardiac arrest; receiving physician discretion.

    • Cut healthy tissue around chest wall in an H pattern, cauterize bleeding vessels, reassess.