Grand Rounds Recap 6.30.21
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Introduction & history of emergency medicine WITH Dr. Pancioli
In 1969, people in Cincinnati were demanding more access to care. This brought about the General Hospital ER, in which patients were seen by interns and residents. At that time, patients were divided by triage nurses into ‘surgical’ or ‘medical’ boxes.
The first chair of emergency medicine at the University of Cincinnati, Dr. Levy, combined the two boxes and decided all patients would be covered by the specialty of Emergency Medicine
After emergency medicine took over care of such patients, our scope expanded, including procedures like intubation, central lines, chest tubes,and reading our own x-rays and billing for them.
In 1968 ACEP was formed with 8 doctors. In 1974 ABEM was formed and there was significant opposition to the development of an emergency medicine board.In 1979 a Co-joint board was formed by physicians from various specialties. It wasn’t until 1989 until Emergency Medicine developed a primary board.
2020 was a year troubled by COVID-19, where emergency medicine physicians were challenged with similar uncertainty and the forging of new paths. At UC we split the emergency department into two care areas in order to safely treat all patients including patients with COVID-19. Now we move forward with the construction of a new state of the art emergency department.
Breaking Bad news WITH dr. Mcdonough
Emergency medicine physicians are often in the position of delivering news of an unexpected diagnosis or the death of a loved one. Delivering difficult news takes compassion, empathy, and practice to do well.
General Process for Delivering Bad News:
PRE-SPIKES - A validated way of delivering bad news
PRE - Prepare: think about what you are going to say, gather information, and know the patient’s name
S - Setting: find a safe, quiet, private space to gather the family and deliver the news. If able leave your phone/pager behind or hand it off to another provider to avoid interruptions, if able get on the same level as the person you are informing (if they are sitting, try to sit down)
P - Perception: Ask the family what they know about the situation
I - Invitation: Ask if this is a good time to talk/provide updates. You can also use this as an opportunity to ‘fire a warning shot’: “I’m sorry but I have some difficult news”.
K - Knowledge: share what you know. Be brief, avoid medical jargon, and be direct. Use definitive words such as death, died, cancer, etc. as applicable.
E - Empathy: empathize with the family
S - Summation and Next Steps: offer support and explain to the patient and family members what the next steps are.
Scenario 1: A Middle aged male presents with a witnessed cardiac arrest at work, EMS finds the patient is Vifb on their arrival. The patient is intubated and undergoes 30 minutes of pre-hospital ACLS care. The patient was transported by EMS and then arrived in the ED in ventricular fibrillation and progressed to PEA. After 60 minutes of total down time, time of death was called. The patient’s wife is in the consult room and only knows he was at work, became unresponsive, and was taken to the hospital.
If a family member interrupts you just as you walk in to notify and blurts out “are they dead?!?” do not withhold the information. Answer them quickly, definitively, and directly then let them process the information and then provide an opportunity for questions.
If the family is on the scene of the inciting incident, they may have more insight into the situation coming in, but don’t assume that they fully understand or have processed the situation - remember television CPR can create a false understanding of resuscitation rates in cardiac arrest.
Patients and family members may blame themselves for bad outcomes or diseases e.g. “I shouldn’t have ignored this symptom for so long, I should’ve made him go to the doctor sooner, I should’ve eaten better”. Try to reassure them as much as possible that it is not their fault.
Scenario 2: A middle aged male presenting with intermittent left arm weakness, vision changes, and progressive headaches. A CT scan demonstrates a new intracranial mass.
When there is uncertainty about the prognosis (or the prognosis is outside of the scope of your specialty or current diagnostic information) it is ok to say so, but try to provide reassurance about what steps will be taken to get that information and that we will work to provide the best outcome while we work to get answers.
Scenario 3: An elderly female presents altered, febrile, and hypotensive. She is found to have a significant leukocytosis, positive urinalysis with white blood cell clumps. She is administered ceftriaxone and has an anaphylactic reaction (the allergy was documented in care everywhere but not in our EMR). She has significant airway edema, develops respiratory arrest which progresses to cardiac arrest, and undergoes an emergency cricothyrotomy.
Disclosure of medical errors does not happen as often as it should and physicians frequently explain medical errors in such a way that families might not actually understand that an error occurred
Tips on how to deliver notification of a medical error, particularly one that was detrimental to patient care:
Give a sympathetic apology
Own the mistake
Give a clear explanation of what happened
Give a clear explanation of how we will take care of the patient/loved one next
Give an explanation of the actions that we will take to prevent the error from happening again
clinical Conundrums WITH Dr. Lafollette
Case 1: A middle-aged female presents with left flank pain. She had a recent ESBL UTI with stent placement which has since been removed. She presents with normal vital signs, a leukocytosis in the twenty-thousands, a normal urinalysis, normal renal panel, a negative pregnancy test, and a normal CT abdomen/pelvis with contrast. The ED physician spoke with the PCP prior to patient discharge who saw the patient the next day and started her on levaquin. She went to an OSH several days later and received an MRI of the lumbar spine which was normal. The patient then returned 2 weeks after the initial encounter with continued left flank pain. On that presentation the patient had a temperature of 100.2, was hypotensive with BP of 89/70, HR of 95, saturating well on room air. Bloodwork revealed a normal CBC, a normal UA, and a normal BMP. an ESR and CRP were obtained and were elevated, an MRI of the thoracic and lumbar spine was obtained and demonstrated T9-T11 Osteomyelitis.
Osteomyelitis: 58% of cases are lumbar, 30% are thoracic. 40% of patients with osteomyelitis will have a normal WBC, however elevated ESR and CRP is 90% sensitive for osteomyelitis and 95% sensitive for discitis.
Case 2: A college aged male presenting with an episode of syncope. The patient was taking a picture of his girlfriend and looked up at the sun causing him to fall backwards and briefly syncopized. He endorses ethanol, tobacco, and IVDU, although none today.
An ECG demonstrates biphasic t-wave in the anterior leaves with inversions in the lateral precordial leads.
The patient was discharged from the hospital with referral to cardiology after reassuring blood work in the ED. He returns a week later after a syncopal episode that occurred while he was standing from a sitting position. At the second encounter, the patient has an ECG with a QRS interval in the 130ms and a QTc over 600ms. The girlfriend was present with the patient at this encounter and noted that the patient has been taking very high doses of loperamide on a daily basis for the last year to deal with withdrawal symptoms after discontinuing suboxone. The patient discontinued loperamide but returned to the ED several times the following week for symptoms of opioid withdrawal (a quick plug for addiction services and advocate treating opiate withdrawal).
Canadian Syncope Rule - A clinical prediction score that may be used to determine their risk of serious adverse events such as death, arrhythmia, myocardial infarction, severe hemorrhage, subarachnoid hemorrhage, pulmonary embolism, or aortic dissection within 30 days of disposition from the emergency department.
Very low risk (Score of -2, or -3) : 0.4-0.7%
Low Risk (Score of 0, -1): 1.2-1.9%
Medium Risk (Score of 1- 3): 3.1- 1.8%
High Risk (Score of 4, 5): 12.9-19.7%
Very High Risk (Score of 6 -11): 28.9 -83.6%
Case 3: A middle aged male presents with difficulty walking over the last week. He presently cannot even walk to the bathroom unassisted. The patient drinks approximately 9 beers a day but the wife has been trying to have him take multivitamins and keep him from drinking. On exam, the patient is dysmetric in his bilateral lower extremities and cannot stand independently when asked (he tried but his legs seem to go limp and uncoordinated). Bloodwork was remarkable for hypokalemia of 2.3, hyponatremia of 109, and serum osmoles of 228. Electrolytes were replenished along with vitamins, but the patient began to seize in the emergency department. The seizure was aborted with hypertonic saline. The patient was admitted to the hospital but left AMA the next day. He returned several days later with osmotic demyelination syndrome.
Goal of sodium correction in chronic hyponatremia is about 6-8 mEq/L in 24 hours with a max of 10 mEq/L in 24 hours in order to prevent osmotic demyelination syndrome.
Remember that with all medicine is the potential for harm.
Consider concomitant alcohol withdrawal seizures
For more on osmotic demyelination syndrome, please see our post from Annals of B-Pod here!
Case 4: An elderly female with abdominal pain, underwent CT abdomen/pelvis which demonstrated metastatic pancreatic cancer
Studies have demonstrated that 55% of patients over the age of 80 presenting with abdominal pain had an acute finding on CT, and 48% had a surgical pathology.
