Grand Rounds Recap 8.7.19
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Wellness Curriculum: Fuel Your Fyre WITH DR. Jarrell
What is Wellness?
Wellness is an active process through which people become aware of and make choices toward a more successful existence. It is both active, and intentional.
Over the past 4 years, wellness has been identified as an increasingly important aspect of training, culminating with ACGME making this a requirement for all residency curriculum in 2017.
Wellness is multifaceted including aspects that are spiritual, physical, emotional/mental, environmental, financial, occupational, social, and intellectual.
Nutrition and Cognition
Evidence supporting healthy nutrition in the healthcare environment
A recent randomized control trial was published looking at physician nutrition and cognition during work hours.
Healthy nutrition group food choice had fewer fluctuations in glucose as well as subjectively improved cognition.
Online survey or Residents
Residents who had lower nutritional needs had higher rates of burnout.
Interestingly, fatigue and burnout rates were not correlated with sleep.
Breakfast is the most important meal of the day
A survey of 100 nurses showed that those who ate breakfast had lower stress, higher cognition, and lower rates of accidents outside of the workplace.
More macro-nutrient complex breakfasts are better than simple carbs.
Lunch
The consensus among nutritionists is that we should eat lunch, but this should not be a large meal - your largest meal of the day should be at breakfast.
Snacking
Mid morning and mid afternoon snacks are good - pick something with high caloric density.
Caffeine
A single cup of coffee has 90-200 mg of caffeine
A systematic cochrane review was published showing that drinking caffeine improves cognition.
The coffee nap - caffeine has a time of onset of 15-60 minutes - taking a short nap of 15-20 minutes immediately after drinking coffee improves cognition. Particularly effective and safe prior to driving home post night shift if feeling too sleepy to do so.
Night Shift Metabolism
Shift workers are more prone to metabolic disorders including cardiovascular disease, obesity, type 2 diabetes, and dyslipidemia.
Hormonal changes during a night shift causes hunger to increases while on shift.
To combat the nutritional challenges of night shift, you can keep healthy snacks at work, plan workouts in advance, pack lunch the night before, and record television shows for later viewing
Temptation bundling with your to do list is a way to maximize your time off shift while also promoting a healthy lifestyle: watch TV shows at the gym, walk to a restaurant/coffee shop.
Contracts WITH mR. Petrovic
When evaluating contract offers from different groups be sure that you are comparing apples to apples.
An offer of a higher base salary with a signing bonus may seem superior to another with lower pay, but be careful to scrutinize the details. The second offer, although not as attractive on its face, may include better benefits such as insurance, retirement, and CME that actually make it better.
Academic and community contracts can be very different in terms of what is negotiable and what is not.
Community groups will appreciate someone who is eager to work hard but who will also be willing to sit on committees that will increase their influence within the greater hospital system.
Academic contracts have become fiercely competitive and so will value someone with a niche. Also be aware that while you will likely be able to negotiate “buy down” on clinical time for your academic activities, the actual time you spend for those activities will probably be more than the clinical hours that you traded.
Non-compete clauses will have a greater effect on community contracts due to higher density of those groups within a small geographic area. Academic centers are typically spread much farther apart than what is applicable.
Know when to ask general questions and when to get down to the business of negotiation.
Initial interview day is a great time to clarify generalities of the system: which service covers what and when, will you have 24-hour support from a specific specialty, etc.
Only after a group has expressed their mutual interest should you feel bold enough to negotiate harder for hours, pay, and benefits.
Bedside Teaching WITH DR. Paulsen
Several challenges affect junior clinical instructors, including, time/availability, lack of expertise/experience, as well as unrealistic expectations of both the instructor and learner.
Creating a Positive Learning Environment
Instructors should set expectations and goals early in the shift, find a balance between supervision and autonomy, have the learner seek encounters with learner centered goals, label feedback when it is being given with both positive and critical feedback, as well as strategies for improvement.
Instructors should pick one goal in each teaching encounter: medical knowledge, communication, procedural skill, attitude, or behavior.
Teaching Tools
Have your learner watch EMRA patient presentations in Emergency Medicine. (https://vimeo.com/132285159)
Creating a Differential - SPIT: Serious, probably, interesting, and treatable. Have the learner list one diagnosis in each category. This can then be expanded based on the learner’s level of experience.
One minute preceptor - The instructor should listen to presentation, ask the learner to commit with a question such as “What do you think is going on?”, probe for evidence and teach one general principle, provide positive feedback and correct any errors, and finally suggest improvements for the next patient encounter.
Direct Observation - Brief your learner in advance that you will be seeing the patient together, observe part of the encounter based on the patient’s chief complaint, and provide specific feedback on the H&P portion of the presentation.
Activated Demonstration - This tool is more geared towards procedures or difficult patient encounters. Ask the learner focused questions at the bedside, narrate as you go and have your learner assist or complete components of the procedure, and debrief afterwards.
Teaching Scripts - Build a case library to present to the learner and use electronic resources to promote learner interaction such as MD Calc. Develop some frequently used mini-lectures to use during down time (this is especially useful in times of high boarding).
Other useful teaching tools are to run your board out loud to teach task prioritization, give documentation tips to the learner while dictating, and teaching consultant communication after a phone call.
Feedback
The common perception among those receiving feedback is that the learner is looking for praise, but actual goal of feedback is criticism. Feedback that is critical will make the learner uncomfortable but ultimately will improve performance.
Feedback is not linear - it should be circular and include the learner’s feedback of the preceptor.
Preceptors should attempt to form an educational alliance with their learner. Praise increased effort from the learner and change the expectation standard based on the learner’s performance to avoid learner burnout.
Label feedback when you give it by asking your learner to self assess (i.e., "“Tell me 2-3 things you learned on shift”).
Feedback tools can be helpful to provide structured feedback.
RIME Model: Evaluate your learner’s skill level using the Reporter, Interpreter, Manager, and Educator labels.
This model is fluid based on an individual learners skill set.
Entrustability Model (Not Yet, Mostly, Fully, and Outstanding).
This is what we use on our formal student evaluations.
Written Feedback
Be specific and highlight specific patient encounters.
Top Practice changing articles: 2018-2019 WITH Dr. Benoit
Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest. Wang, JAMA 2019.
Original Article: https://jamanetwork.com/journals/jama/fullarticle/2698491
The supraglottic device group had better outcomes, although this is conflicting with more recent studies that support endotracheal intubation.
Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging. Vandenberg, JEM 2019.
Original Article: https://www.sciencedirect.com/science/article/pii/S0736467918310588?via%3Dihub
CT found more clinically significant spinal fractures than xray.
Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. van der Pol, NEJM 2019.
Original Article: https://www.nejm.org/doi/10.1056/NEJMoa1813865
The YEARS criteria for risk adjusted D-dimer testing was validated in pregnant patients and significantly lowered rates of CTPA without missing clinically significant VTE.
Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Teran, Resuscitation 2019.
Original Article: https://www.sciencedirect.com/science/article/pii/S0300957218309766?via%3Dihub
32 of 33 patients had a clinically significant finding on TEE.
Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. Sperry NEJM 2018.
Original Article: https://www.nejm.org/doi/full/10.1056/NEJMoa1802345
Patients who received plasma had improved 30 day mortality.
Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. Pluymaekers, NEJM 2019.
Original Article: https://www.nejm.org/doi/full/10.1056/NEJMoa1900353
There was no difference in achieving normal sinus rhythm at 4 weeks between the two groups.
Diagnostic yield of non-invasive imaging in patients following non-traumatic out-of-hospital sudden cardiac arrest: A systematic review. Petek, Resuscitation 2018.
Original Article: https://www.sciencedirect.com/science/article/pii/S0300957218308608?via%3Dihub
There were clinically significant findings in 10-45% of head CT’s, 14-54% of chest CT’s, and 8-41% of abdominal CT’s.
A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins NEJM 2018.
Original Article: https://www.nejm.org/doi/full/10.1056/NEJMoa1806842?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed
Patients who received epinephrine had higher rates of 30 day survival with no difference in favorable neurologic outcomes.
Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest. Nordberg, JAMA 2019.
Original Article: https://jamanetwork.com/journals/jama/fullarticle/2732572
No difference in 90 day neurologic outcomes.
Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease. Nguyen, JAMA IM 2019.
Original Article: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2719198
Scheduled dialysis improved 1 year mortality and reduced healthcare spending compared to emergency only dialysis.
Evaluation of Outpatient Cardiac Stress Testing After Emergency Department Encounters for Suspected Acute Coronary Syndrome. Natsui, Annals of Emergency Medicine 2019.
Original Article: https://www.sciencedirect.com/science/article/pii/S019606441930054X?via%3Dihub
No difference in MACE between patients who had stress testing in less than 72 hours versus within 30 days.
Effect of Initial Bedside Ultrasonography on Emergency Department Skin and Soft Tissue Infection Management. Mower, Annals of Emergency Medcine 2019.
Original Article: https://www.sciencedirect.com/science/article/pii/S0196064419301040?via%3Dihub
There was no difference between ultrasound and clinical evaluation if clinician is confident about the presence of an abscess. Ultrasound did change drainage decisions in 25% of cases when the provider was uncertain.
Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. Ma NEJM 2019.
Original Article: https://www.nejm.org/doi/full/10.1056/NEJMoa1813046
Patients who received alteplase between 4.5-9 hours after symptom onset with favorable perfusion imaging had improved modified Rankin scores at 90 days.
Single-dose versus 7-day-dose metronidazole for the treatment of trichomoniasis in women: an open-label, randomised controlled trial. Kissinger, Lancet 2018.
Original Article: https://www.sciencedirect.com/science/article/pii/S1473309918304237?via%3Dihub
A 7 day course of 500 mg metronidazole BID had higher cure rates than a single dose of 2 grams.
Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Trial. Khatri, JAMA 2018.
Original Article: https://jamanetwork.com/journals/jama/fullarticle/2687354
No difference in outcomes at 90 days, although this was an under powered study.
Decolonization to Reduce Post Discharge Infection Risk among MRSA Carriers. Huang, NEJM 2019.
Original Article: https://www.nejm.org/doi/10.1056/NEJMoa1716771
The Chlorhexidine + Mupirocin group had reduced rates of recurrent MRSA.
Prospective study of the sensitivity of the Wood’s lamp for common eye abnormalities. Hooker, Emergency Medicine Journal 2019.
Original Article: https://emj.bmj.com/content/36/3/159.long
The slit lamp has higher diagnostic utility than the Wood’s lamp.
Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. Hayden, NEJM 2018.
Original Article: https://www.nejm.org/doi/full/10.1056/NEJMoa1716197
Both single dose baloxavir and 5 day oseltamivir reduced duration of flu symptoms and there was no difference between the two medication. Both are high-cost medications.
Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Dalziel, Lancet 2019.
Original Article: https://www.sciencedirect.com/science/article/pii/S0140673619307226?via%3Dihub
No difference in resolution of seizure activity at 5 minutes in pediatric patients who received levetiracetam or phenytoin.
Moose–Motor Vehicle Collision: A Continuing Hazard in Northern New England. Clark, Journal of the American College of Surgeons 2019.
Original Article: https://www.sciencedirect.com/science/article/pii/S1072751519300778?via%3Dihub
Moose collision resulted in significantly higher mortality than deer collisions.
Discharge, Transfer, or Admit: Hand in the ED WITH DR. Betz
Nearly two thirds of patients are inappropriately transferred regardless if they are evaluated by an emergency physician or orthopedic surgeon (however a limited study as necessity was retrospectively derived for need for attending intervention). Despite this, many patients can be discharged with close follow up.
Hand Exam
ROM: Test extension and flexion at all joints.
Bony Tenderness: Palpate the anatomic snuffbox, scapholunate ligament, hook of the hamate, and IP joint of the thumb. Ulnar deviate the wrist, axial load the thumb, and check for thumb laxity at 30 degrees.
Neurovascular function: Check the radial pulse and capillary refill in all digits.
Radial nerve - thumb up
Ulnar nerve - peace sign
Median nerve - OK sign,
Also check thumb to pinkie for function of the recurrent branch of the median nerve.
Always ask about hand dominance and occupational history.
Case 1: Mallet finger
Rupture/avulsion of the distal extensor mechanism of the finger.
Splint the DIP only in extension for 6 weeks, 24 hours/day. Leave the PIP free to allow use of the finger.
Follow up with hand surgery in 1-2 weeks.
Case 2: Jersey finger
Avulsion of the flexor digitalis profundus.
Splint in ulnar or radial gutter depending on affected digit.
Follow up in 2-3 days for operative fixation within one next week.
Case 3: Central band rupture
Presents with Boutonniere Deformity after a volar finger dislocation.
ELSON Test - isolate the PIP on the edge of a table or with the patient’s other hand. The injured DIP will extend but the PIP will not.
Splint the finger in extension at the PIP.
Follow up with hand surgery in 2-3 days.
Case 4: Cat bite Infections
These have a high infection rate, and all need to be treated with antibiotics.
Patients with evidence of spreading injury should be transferred to a facility with hand surgery given high operative need if failing outpatient antibiotics.
Case 5: Displaced distal radius fracture (Colles fracture)
Attempt reduction, especially if there is dorsal angulation.
Perform a hematoma block with 10-15 mL of Lidocaine directly into the fracture.
More than 1 reduction attempt only changed clinical outcomes in 5% of cases, so avoid repeat reduction attempts.
Operative management is indicated for radial shortening, dorsal angulation, and radial inclination.
Place a sugar tong splint with the wrist in slight extension (Cotton-Loder Position).
The most common complication with this injury is carpal tunnel syndrome.
Follow up with hand surgery in < 1 week if there are signs of median nerve injury.
Case 6: Tuft’s fracture
Classic dogma requires nail removal in a subungal hematoma that occupies > 50% of the nail.
This has been debunked in recent literature and should not be an indication for nail removal.
You can perform trephonation if the injury occurred < 24 hours ago and occupies > 25% of the nail.
Antibiotics are not routinely indicated.
The nail should be removed if it is avulsed, and the nail should then be replaced to stent the germinal matrix.
Case 7: Lunate dislocation
Scapholunate injuries are classified along a spectrum of worsening injury.
Scapholunate dislocation: tear of the scapholunate ligament.
Perilunate dislocation: volar dislocation of the capitate and lunate.
Lunate dislocation: volar dislocation of the lunate only.
25% of lunate dislocations have injury to the median nerve.
Attempt closed reduction
This procedure is very painful and often requires procedural sedation.
Hang the hand in a finger trap, extend the wrist and put volar pressure on the lunate, and move the wrist into flexion.
Place the patient in a sugar tong splint.
Transfer or admit for operative fixation with hand surgery, even if the dislocation is reduced.
Case 8: High pressure injection finger Injury
This requires an emergent hand consult.
If operative management is delayed > 10 hours, amputation rates significantly increases.
Paint and solvent injections have higher morbidity rates.
Case 9: Digital nerve injury
This often occurs with volar lacerations of the palm or fingers.
Make sure to evaluate each branch of the digital nerve during your exam.
Follow up with hand surgery in 3-5 days.
Case 10: Radial nerve neuropathy (Saturday night palsy)
Patients present with wrist drop and inability to extend the wrist/fingers, usually after sleeping with the arms held above the head.
Symptoms often resolve within 4 weeks.
Place the patient in a velcro volar wrist splint.
Case 11: Hook of the hamate fracture
This injury is caused by forced ulnar deviation (usually swinging a golf club or baseball bat).
This fracture is often missed on xray unless a carpal tunnel view is obtained.
Patients can also present with an associated ulnar neuropathy.
Place the patient in an ulnar gutter splint.
Follow up with hand surgery in one week - this fracture has a high rate of non-union and ulnar nerve injury requiring operative management.
