Grand Rounds Recap 7.17.24
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LEADERSHIP CURRICULUM: styles of leadership WITH dr. MCdonough
Leadership styles:
Coercive vs. Authoritative
Coercive demands immediate compliance whereas authoritative mobilizes people toward a vision
Use coercive in a crisis, to kick start a turnaround, or with problem employees
Use authoritative when changes require a new vision, or when a clear direction is needed
Affiliative vs. Democratic
Affiliative creates harmony and builds emotional bonds whereas democratic forges consensus through participation
Use affiliative to heal rifts in a team or to motivate people during stressful circumstances
Use democratic to build buy-in or consensus, or to get input from valuable employees
Pacesetting vs. Coaching
Pacesetting sets high standards for performance whereas coaching develops people for the future.
Use pacesetting to get quick results from a highly motivated and competent team
Use coaching to help an employee improve performance and develop long-term strengths
Social EM Grand Rounds: Interpersonal and community violence WITH drs. jarrell and kimmel
Violence is a social determinant of health
Direct injury
Vicarious trauma
Cardiovascular health
Psychological health
Birth outcomes
Risky sexual behavior
Substance use
Socioeconomic health
The link between violence and direct injury is obvious, however there is evidence linking exposure to violence to other health consequences.
Social disadvantage increases a person’s likelihood of exposure to violence.
Social-Ecological Model of Violence
This model considers the complex interplay between individual, relationship, community, and societal factors. It allows us to understand the various factors that put people at risk for violence or protect them from experiencing or perpetrating violence.
This model also suggests that preventing violence requires simultaneous action across multiple levels. This approach is more likely to sustain prevention efforts over time and achieve impact on the population as a whole
Intimate Partner Violence
Intimate partner violence refers to physical, sexual, or psychological harm by a current or former partner or spouse; often used interchangeably with domestic violence
IPV is an unfortunately prevalent phenomenon. A study that began in 2010 and is currently ongoing has found that approximately 25% of women experience some sort of physical or sexual violence or stalking by a partner in their lifetimes.
Victims of IPV are likely to seek care at emergency departments at higher rates than the general population.
Up to 10% of women in the ED at a given time are there for a complaint related to IPV
50% lifetime prevalence of IPV for women surveyed in the ED
ED use is common in the two years preceding murder by an intimate partner
Firearm Violence
200 daily ED visits for non-fatal firearm injuries
Compared to other high-income countries, U.S. rates are 25 times that of other countries for homicide and 10 times greater for suicide.
ACEP believes that emergency medicine physicians play a key role in educating patients on safe firearm storage.
Human Trafficking
Top 5 Risk Factors for Sex Trafficking
Substance use
Runaway/homeless youth
Unstable housing
Mental health concern
Recent migration/relocation
Top 5 Risk Factors for Labor Trafficking
Recent Migration/relocation
Self-reported economic hardship
Unstable housing
Criminal record/criminal history
Substance use concern
Trauma Informed Care
A program, organization, or system that is trauma-informed realizes the widespread impact of trauma nd understands potential paths for recover; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist retraumatization
It is important to understand how violence affects health, recognize signs of trauma in our patients, employ the principles of trauma informed care, and minimize retaumatization as much as possible.
ultrasound grand rounds: early pregnancy ultrasound WITH dr. stolz
Risk Factors for Ectopic Pregnancy
Prior ectopic
Surgery
Infection
Assisted reproductive technologies
IUD
50% of patients have no risk factors
Symptoms of Ectopic Pregnancy
Abdominal pain:
62% of patients will have no abdominal pain
Vaginal bleeding:
35% of patients will not have vaginal bleeding
Bleeding may help discern between a viable intrauterine pregnancy and non-viable
It is not helpful in distinguishing between a spontaneous abortion and ectopic
Sonoanatomy: Rule out Ectopic
You should be able to visualize the fundus of the uterus, endometrial stripe, and cervix
You should sweep fully in both the transverse (left to right) and longitudinal (superior to inferior) planes
If there is fetal cardiac activity, obtain fetal heart rate using M mode
Transabdominal ultrasound for early pregnancy can be optimized by obtaining with the patient fully supine, with a full bladder, with probe under folds or pannus, and utilizing a linear probe.
Transvaginal ultrasound images can be optimized by obtaining a transvaginal ultrasound first, having the patient empty their bladder, and using gel inside the probe cover as well as on the outside.
What is an IUP?
A gestational sac and a yolk sac in the mid/upper endometrium
Summary:
Be systematic
Don’t rely too heavily on the quantitative HCG
Be obsessed with the endometrial stripe
landmark studies of EM WITH dr. freiermuth
Airway - Anticipating Difficulty
Reed et al. “Can an airway assessment score predict difficulty at intubation in the ED?
Population: ED patients requiring intubation
Prospective observational study with a total of 156 patients from June 2002-September 2003
Assigned scores to the LEMON criteria
Defining Outcome:
Cormack-Lehane score 1 = easy
Cormack-Lehane score 2,3,4 = hard
Breathing - How much air is too much air?
The ARDS Network “Ventilator with Lower Tidal Volumes Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome”
Population: intubated patients with acute decrease in arterial O2 partial pressure with infiltrates on CXR and no significant signs of left atrial hypertension.
Randomized controlled trial with 861 patients from March 1996 - March 1999. Included 10 academic hospitals.
Intervention: 12 ml/kg predicted body weight vs 6 ml/kg
Outcome: death before discharge or ability to breathe on own; vent free days
Secondary: days without organ failure, occurrence of barotrauma
Circulation - FAST EXAM
Melniker et al. “Randomized Controlled Clinical Trial of Point-of-Care, Limited Ultrasonography for Trauma in the Emergency Department: The First Sonography Outcomes Assessment Program Trial”
Population: ED patients with trauma to the torso
Randomized controlled trial that enrolled 262 patients from 2 academic ED’s from 2002-2003
Intervention: FAST vs Usual care
Outcome: time from ED arrival to OR transfer
Secondary: CT utilization, complications, charges
