Grand Rounds Recap 7.26.17

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Morbidity and Mortality with Dr. Lagasse

Case One: A middle aged male with multiple presentations to the Emergency Department over several months for atraumatic back pain. Ultimately the patient presents again with back pain and is found to have renal failure and hypercalcemia is diagnosed with multiple myeloma. 

  • Although we are all taught about the "red flags" for back pain (e.g., a history of cancer, IV drug use, fevers, weight loss), there is little evidence to support these.
  • However, in general, imaging should be obtained in the following situations: if there is concern for pathologic fracture; if the patient is greater than 50 years of age AND has had back pain for longer than 6 weeks of pain that has failed conservative management.
  • The American College of Radiology recommends plain films as the initial imaging modality of choice in most cases to rule out fracture, but does recommend CT scan if you have a high level of concern for pathologic fracture.

Case Two: A middle aged male with a history of HTN and DM presents with chest pain and shortness of breath. He is found to have some lateral T wave inversion on his EKG and an unremarkable lab evaluation. His CXR is read as mild tracheal deviation, possibly due to thyroid tissue. He is placed in observation for a chest pain rule out, which is ultimately negative. However, a CT of the chest was performed due to his abnormal CXR, and he was found to have a large mediastinal mass concerning for lymphoma. 

  • In making decisions in the Emergency Department, we often utilize Type 1 Processing, which is fast and intuitive, but prone to biases and cognitive errors. Type 2 Processing instead is analytical and deliberate, and is used when a patient manifests symptoms which do not fit with a common presentation. 
  • In the above case, the patient presented with chest pain and was worked up in a standard fashion for chest pain via Type 1 Processing. The CDU team realized that the patient's CXR was abnormal, and used Type 2 Processing to perform a more thorough workup, finding the etiology of the patient's symptoms.
  • Common cognitive errors include:
    • Anchoring: Locking in on a diagnosis early on and failing to adjust the initial impression based on new data.
    • Confirmation bias: Looking for data to confirm a diagnosis rather than looking for disconfirming data to refute the diagnosis.
    • Diagnostic momentum: A diagnosis is considered definite through propagation even though data refutes the diagnosis.
    • Search-satisfying: Calling off a search once a positive result is found.
  • To avoid these cognitive errors, the provider must be aware of the potential for bias and actively practice "debiasing strategies," which include developing insight, being aware of clinical scenarios that are more prone to error, working through a forced differential diagnosis, and using data to augment your clinical impression.
  • This case also highlights the importance of reviewing your own imaging.

Case Three: A woman in her 50s with a history of DM, CAD and chronic liver failure presents with hyperglycemia and weakness. She is found to be tachycardic and hypotensive, with an elevated lactate and significant leukocytosis. She is also found to have new onset acute renal insufficiency with hyperkalemia. She is treated for the hyperkalemia and ultimately for sepsis, although the time to antibiotics is delayed.

  • DKA is frequently precipitated by infection, and early broad-spectrum antibiotics are often appropriate, even if a source isn't readily obvious.
  • The 2016 International Guidelines for Management of Sepsis and Septic Shock recommend empiric broad-spectrum antibiotics within one hour of identification of sepsis, as well as obtaining blood cultures prior to antibiotic administration if possible.
  • Increased time to antibiotic administration in patients with severe sepsis and septic shock is associated with increased in-hospital mortality.

Case Four: A middle aged female with a history of alcoholic cirrhosis presents with syncope, nausea and vomiting. She is found to be tachycardic, jaundiced and has ascites on exam. Labs are notable for a lactate of 9, as well as chronic anemia and thrombocytopenia. A diagnostic paracentesis is performed in the ED to evaluate for SBP, which was negative, and she is admitted to the hospital. While in the hospital, the patient drops her hemoglobin, and is transfused 2U PRBC with a negative CT of the abdomen. She is discharged but returns with abdominal pain and is found to have abdominal ecchymosis on exam. A CT of her abdomen shows a rectus sheath hematoma with active extravasation. The patient goes to Interventional Radiology, where the inferior epigastric artery was embolized. 

  • Common complications paracentesis include persistent leakage of ascites fluid, localized infection and damage to underlying structures, including vascular structures.
  • An unrevealing diagnostic paracentesis does not completely rule out SBP; follow the cultures.
  • Patients requiring a paracentesis are often coagulopathic and thrombocytopenic; an elevated INR or decreased platelet count are not contraindications to the procedure. Active DIC or an acute abdomen requiring surgery, however, are contraindications to performing a paracentesis.
  • We can mitigate our complication rate by: choosing an appropriate site away from known vascular beds; using ultrasound guidance both for site selection and for vessel identification; and inserting your needle towards the patient's spine to avoid the inferior epigastric arteries, which run posterior to the abdominal wall and can be injured with a more shallow approach.

Case Five: A college aged G2P1 with no prenatal care who estimates herself as 3 months pregnant presents with abdominal pain and vaginal bleeding. She ultimately miscarries a fetus in the Emergency Department that is approximately 20 weeks old.

  • There are no discrete guidelines about the evaluation of a pregnant patient with unknown dates who presents with vaginal bleeding.
  • Our role in the ED is to rule out or evaluate for an ectopic pregnancy, active hemorrhage, placental abnormalities or uterine rupture.
  • Early ED management should involve standard laboratory evaluation as well as a bedside ultrasound and pelvic exam as indicated.
  • At our institution, OB-GYN should be involved for any cases with heavy vaginal bleeding or hemorrhage, concern for ectopic pregnancy, an exam with products of conception in the vault, or an open cervical os. 

Case Six: A middle aged gentleman with a history of hypertension and diabetes presents with foot pain. He is tachycardic with a low-grade temperature, and is found to have mild warmth and erythema over the first MTP joint. He is found to have a slightly elevated lactate, a leukocytosis of 16 and an elevated ESR/CRP. Blood cultures were sent. An x-ray is read as a possible small foreign body over the first great toe but otherwise unremarkable. Arthrocentesis is performed with a dry tap. He is sent home with indomethacin, sulta/TMP and cephalexin and referred to podiatry. He returns to the ED for positive blood cultures, and at that time is found to have a large abscess over the joint. He is ultimately found to have osteomyelitis and admitted to the hospital.

  • Diabetic foot infections often occur due to small local trauma or foreign bodies.
  • Per the IDSA, patients with local swelling, erythema, warmth, tenderness or drainage are considered to have a mild infection. Patients with erythema >2cm are considered to have a moderate infection, and anyone with SIRS criteria with these physical exam findings are considered to have a serious infection.
  • Wounds that probe to bone should be treated as osteo until proven otherwise.
  • Elevated inflammatory markers can be helpful but clinical gestalt should override an equivocal laboratory evaluation.
  • Consider admission for patients with serious diabetic foot infections.

Leadership Curriculum with Drs Hill and Stettler

The Tenets of a Leader

  • What makes a great leader? Are there specific tenets possessed by individuals who are considered "great," or is this a situational construct?
  • We discussed John Wooden's Pyramid of Success, based on the mantra of "before you can lead others, you must be able to lead yourself." Tenets such as industriousness, friendship and loyalty form the basis for success, and personal values like poise and confidence lead to competitive greatness. 
  • The psychology literature looks at the concepts of the emergence of a leader and his or her effectiveness with regards to personality factors. The personality trait of extraversion had the strongest correlation with leadership, as did the tenets of conscientiousness and being open to experience. Leaders who have a positive attitude are collaborative with their staff are more successful.
  • In the business literature, they looked at what sets successful CEOs apart. They found that individuals who were quick decision makers, adapted proactively and projected consistency were the most successful. 
  • In the world of Emergency Medicine, characteristics that departmental chairs deemed necessary for their success included formalized leadership and administrative training, scholarly productivity, interdepartmental collaborative experience, and skill with conflict resolution and finances. Personal characteristics included trustworthiness, the ability to collaborate, and being an effective decision-maker.

Leadership Panel - Drs Fermann, Fernandez, Leenellett, McDonough and Ronan

  • What do you think is the single most important trait in being a leader?
    • Dr. Fermann: Balance. Good leaders can deploy different assets to different settings. Those who are multi-faceted and can change their approach are more successful.
    • Dr. Fernandez: Resiliency. Not all endeavors will be successful; bouncing back is important.
    • Dr. McDonough: Trustworthiness. You must be honest and genuine with those you are leading, but also trusted to follow through with your word.
    • Dr. Ronan: Knowledge of your team. Each individual brings something unique to the table; good leaders can capitalize on every member of the team.
  • Can you name one moment or principle that's led to your success?
    • Dr. Leenellett: Putting patients first and leading by example. Putting in long hours and working hard. 
    • Dr. McDonough: Actively seeking out opportunities, putting yourself out there and saying yes when asked -- at least initially as you're starting out!
    • Dr. Fernandez: Choosing an area of interest that needed work and getting involved. Know what you want and lay out a plan for it, but keep yourself open to new opportunities. 
    • Dr. Fermann: See the big picture as much as you can. Putting yourself in a place where you can function as a fundamental part of the organization can lead to success. Having mentors who push you to see the big picture is important early on.
  • How do you choose between the myriad of opportunities presented to you as a resident or junior faculty?
    • Dr. Fernandez: When I'm given a task or an opportunity, I take it to someone I trust and have them vet it. You need a network of people who you trust to help you grow.
    • Dr. McDonough: When you're still undifferentiated with regards to your career focus, you should be more open to opportunities. Try everything once. If you don't like it, move on, but you may be surprised by what you like. 
  • What is one thing you would advise people to avoid doing?
    • Dr. Fermann: At some point in your career you will face an important decision that you have to make. Understand that the grass is not always greener on the other side. Discuss it with your trusted advisors or peers but choose what makes you happy.
    • Dr. Fernandez: Don't burn bridges. You never know who you will need to work with in a new or different capacity down the road, and whose skills you will need in the future.
    • Dr. McDonough: Be a good listener and make people feel that they're being listened to. Don't just speak your opinion without listening to others'.
    • Dr. Leenellett: Find balance in your life. Do what makes you happy. Even if you're successful at your job, if you don't feel balanced or aren't happy with your work, seek out change.
    • Dr. Ronan: Sometimes you have to change your expectations or ultimate goals, especially while working with a team. Realizing when you have to reset your own expectations or change course in order to accomplish the goals of the group is important.
  • For the residents and med students in the room, what would you advise them to do now in order to get where you are?
    • Dr. Ronan: Identify a mentor. Talk to those who are doing what you're interested in. Make a plan and focus on the initial steps. 
    • Dr. Leenellett: Dip your toe in and see if you really like your area of interest. If it's operations, get involved in a project, join a national committee, become a resident assistant medical director or simply develop a mentorship relationship with a medical director. See if you like it!
    • Dr. Fernandez: In health care, legitimacy comes from being a good clinician first and foremost. Work hard in residency and develop your clinical skills to augment your reputation in extra-clinical projects and endeavors. If you're interested in informatics, there is a fellowship that leads to boarding.
    • Dr. Fermann: Every day in the ED, you have to deal with conflict management and resolution. This is a unique skill set that we develop by virtue of navigating the myriad relationships and challenges in the ED. 
  • What did you do as a mentee to augment your relationship with your mentor?
    • Dr. McDonough: A mentorship works much better when it is mentee-driven. Be active in reaching out to your mentor and ask for what you need. 
    • Dr. Leenellett: Reach out to your mentors and ask for advice. Your mentors may have unique information about the political or social background regarding the issue you're facing.
  • How do you balance maintaining a professional distance from those you lead while still fostering a sense of team and community?
    • Dr. Ronan: As a leader you want to be approachable with open lines of communication. However, you can lose the respect of those you lead by being unprofessional in their eyes. It's a difficult balance to strike and is very challenging for leaders. We must remember that we are setting an example for those we lead.
    • Dr. Fernandez: In our environment, a leader gains legitimacy by manifesting his or her clinical skills. We are much more willing to follow the suggestions of our leaders if we trust them clinically. 
    • Dr. McDonough: As a program director, you often need to have difficult discussions with residents. If you have a close personal relationship with the resident, it adds another level of complexity to those conversations and can ultimately be detrimental to the success of the resident. Transitioning from resident to attending can be difficult. 
  • Any particular tips or tricks about being a leader?
    • Dr. Fermann: Know what your organization's standards are, specifically with regards to communication. If you have an administrative role, you need to be responsive and available. You have to be present and show up. Bring data with you and be prepared. 
    • Dr. Ronan: Being able to complement or reward the individuals you work with is important. This builds confidence in your team, and fosters a collaborative environment that's ultimately more successful.
    • Dr. Fernandez: Don't hold meetings unnecessarily. Value people's time, and only ask for meetings when it's important. If you're going to have a meeting, make sure there's a structured agenda that will accomplish something. 
    • Dr. Leenellett: Dress professionally so people will take you seriously. How they see you is how they treat you. Get your facts straight and do your research before an important meeting occurs so that you can be as prepared as possible. Discuss the issue with the important stakeholders beforehand to support your position. 
    • Dr. McDonough: If you think a meeting is going to be contentious, physically go to them to make them feel more comfortable. Start the discussion with a question instead of an accusation. Give credit to everyone else for a team success, but personally accept failures as your own. 

Consultant of the Month with Dr. Martha Ferguson

Ano-Rectal Conditions for the Emergency Physician

  • As with all physical exam skills, knowing the normal anatomy (and the correct anatomic terms) for the area is important for diagnosing and describing pathology to a consultant. 
  • When doing a rectal exam, understand that this is often uncomfortable or embarrassing for the patient. Talk to them and tell them what you are going to do before you do it.
  • Use specific questions to fill in the blanks because patients may not provide the information. For example, ask about bleeding, pain, swelling, fever, tenesmus or diarrhea.
  • A hemorrhoid is a diagnosis, not a symptom; internal hemorrhoids are vascular cushions and external hemorrhoids are subcutaneous thromboses at the anal verge.
  • Trust your clinical gestalt. Do the patient's symptoms match the diagnosis you're considering?
  • Painful bleeding usually occurs below the dentate line. 
  • Tenesmus is often a sign of a deep space abscess. 
  • Benign anal fissures are usually in the posterior midline (90%) or anterior midline (10%). Anything off the midline is not normal, so consider other possible etiologies including STIs, TB, malignancy or underlying deep space abscess.
  • For anorectal abscesses, packing material can often cause more problems than it solves, especially as it is very hard for patients to change the packing.