Grand Rounds Recap 8.15.18

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Research Summit with Dr. Adeoye

Why Research:  It is an opportunity to help define the practice in Emergency Medicine.  What are we currently doing in EM and how can we make it better?

What initial steps should you take with your idea?

  1.  Identify if it is a new idea (review literature, talk to colleagues) 
  2.  Refine your idea (develop hypothesis, develop protocol)
  3.  Discuss with others (clinicians, methodologists, regulatory experts)

The best projects:

  1. Answer a clinically relevant question. 
  2. Have early collaboration between clinicians, methodologists, and regulatory experts.  
  3. Align with your interests.

Ultrasound Grand Rounds with Dr. Stolz

POCUS and Early Pregnancy

Our protocol for early trimester ultrasound is here.

Scanning:

  • Make sure you get two orthogonal views (sagital and transverse) and sweep fully. Look outside the uterus to look at other structures.  Abnormal findings may be missed if you focus only on finding a gestational sac in the uterus.  
  • items to evaluate on every scan: Free fluid, gestational sac, yolk sac, cardiac activity, positioning within uterus, adnexa.   

Pregnancy and no IUP = pregnancy of unknown location: ectopic pregnancy (7-20%), spontaneous abortion (50-70%), early pregnancy.  There is a lack of consensus on how to treat these patients.  

Ectopic Pregnancy:

  • 1-2% of all pregnancies, 7-13% of symptomatic ED patients, #1 cause of first trimester maternal death, 10% of all maternal mortality.
  • Risk factors: prior ectopic, surgery, infection, assisted reproductive technologies, IUD.  However, 50% have no risk factors. 
  • Sonographic findings: no IUP, free fluid (especially complex free fluid), adnexal mass, tubal ring/bagel sign (hyperechoic ring with anechoic central area), pseudogestational sac. Note: corpus luteum cyst looks similarly to tubal ring/bagel sign.

There are several types of ectopic pregnancies depending on the location of the ectopic:

  • Tubal: gestational sac located in the fallopian tube.
  • Interstitial: gestational sac located in interstitial portion of the Fallopian tube.  These pregnancies can grow much larger before rupture than a traditional tubal ectopic.
  • Heterotopic: presence of an ectopic pregnancy and and IUP.
  • Cervical: gestational sac located within cervix.
  • Angular: not technically an ectopic pregnancy, a gestational sac implanted just medial to the utero-tubal junction.
  • Cornual: gestational sac within the cornu of the uterus (this term can be confusing, see this post for further clarification)
  • Abdominal: gestational sac within the abdomen
  • Ovarian: gestational sac within the ovary

Personal Finance with Dr. Shaw, Dr. Loftus, and Dr. Willing

Debt Management:

  1. Background:
    • 75% of graduates have medical debt, average debt is $190k
    • Physician income is not growing at an equal rate
  2. Definitions and Terms:
    • Deferment: temporary suspension of loan payments, but interest still capitalizes at the end of deferment period on unsubsidized loans
    • Forbearance: temporary suspension of loan payments or reduction in payments due to financial hardship, interest capitalizes on ALL loans
    • Grace period: suspension in payments for 3-6 months post medical school
    • Discretionary Income = Annual Income - (150% x Federal Poverty Limit)
  3. Loan Strategy Repayment Plans:
    • Public Service Loan Forgiveness
      • After 120 payments while working for a qualifying employer (government or 501c3), federal loans forgiven tax-free
      • You MUST be in a qualifying loan repayment plan (RePAYE, PAYE, IBR, ICR)
      • Makes most sense with high debt burden/loan principal or lengthy training (fellowship)
    • Refinancing
      • Don't refinance during residency (for federal loans)
      • Don't refinance if pursuing PSLF (for federal loans)

Retirement and Savings

  1. Financing Children's Education
    • Coverdell Education Savings Account
      • Post-tax contributions of up to $2k per year
      • You can spend income flexibly to cover education expenses
    • 529 College Savings Plan
      • Post-tax contributions of up to $15k per year
      • No flexible spending
  2. Retirement Savings
    • Employee Sponsored Plans
      • 401k and 403b: pre-tax contributions.  If employer give you match, this is FREE MONEY.  Invest in this first.  It is limited to $18.5k per year, with employer contributions your account can have up to $55k.
      • Roth IRA: post-tax contributions, up to $55k per year.

Financial Pitfalls: Residency and Beyond

  1. Common Mistakes
    • Failing to live within means
    • Incurring more debt
    • Failing to pay off debt
    • Buying a big house
    • Not funding retirement
    • Buying a boat by yourself
    • Not getting disability insurance
  2. Make a Budget - What to Include
    • Fixed Expenses: utilities, debt, mortgage, car payment
    • Variable Expenses: dining, fun stuff

Jobs/Contracts with Dr. Stettler, Dr. Ryan, and Steve Petrovic

Job Search:

Timing: Depends on situation.  If you want a specific job or geographic area, can start as early as spring of PGY-3 year.  Most others will start late summer of PGY-4 year.  

Methods:

  • Academic: use your PD/chair as advocate  
  • Community: use your contacts/alumni for recon and introductions

Compensation:

  • Base Pay (set salary for a set or projected amount of hours)
  • Variable Compensation (RVUs, group returns, metric based etc)
  • Extras (overtime, shift differential)

Benefits:

  • Health Insurance
  • Tuition Remission
  • Retirement
  • CME/Tax Deferred Accounts/Other

Malpractice:

  • Claims made vs occurrence 
    • Who pays the tail?
    • Does it vary by when you leave the group?

Cost of Living:

  • Home, transit, parking, schools etc

Extras:

  • Office space/admin support, computer/furniture
  • Moving allowance/sign on bonus

What is negotiable (academic job/community job)?

  • Salary: Rarely/occasionally
  • Hours: Commonly/occasionally
  • Benefits: never/never
  • Signing Bonus: frequently/always
  • Non-compete: occasionally/occasionally
  • Vacation: occasionally/occasionally

The Agitated Patient With Dr. Stettler

Approach to the Agitated Patient:

  1. What is the patient's likely source of the agitation?
  2. What are the dangers to my patient with chemical restraint? 
  3. What are the dangers to my patient and my team in the absence of chemical restraint? 
  4. What are my goals of chemical restraint?
  5. What agent is safest and most efficacious in achieving those goals?

Cases:

1. 87F from nursing home with agitation, stable vitals, well appearing:

  • Goal: facilitate medical workup
  • Orally: Quetiapine 25-50 mg, repeated up to 400mg 
  • IV: Haloperidol 1mg IV every 30 minutes as needed, may repeat x 4
  • All antipsychotics increase risk of death in dementia patients
  • Benzodiazepines worsen delirium, avoid in elderly patients

2. 21M who was in an MVC, GCS 11, mildly tachycardic, soft BP:

  • Goal: facilitate medical workup. 
  • If you want him immediately sedated: Intubate
  • Other options: ketamine 1mg/kg; antipsychotics (olanzapine/haloperidol)

3. 57F AMS at home, old EKG with QTc of 498ms

  • Torsades is rare with administration of common doses of antipsychotics
  • Don't hold needed meds due to QTc concerns
  • Midazolam / benzodiazipines have less QTc effects than other agents

GI Foreign Bodies with Dr. Plash

Rectal Foreign Bodies:

  • Imaging of choice:
    • Plain film
  • What can I remove?
    • Items that are not dangerous if ruptured
    • Items you can feel
    • Items below the sigmoid colon
  • Technique:
    • Analgesia/Sedation: IV pain meds with consideration of conscious sedation or an anal ring block
    • Positioning: lithotomy position
    • Foley Catheter: place past foreign body, inflate it.  Can either pull to remove, but also eliminates suction effect proximally to help with manual removal
    • If successful: observe, home with return precautions
    • If failure: consult GI/Surgery

Body Packers: deliberate action to smuggle drugs. CT is the imaging of choice.  If asymptomatic, admit to ICU with whole body irrigation.  If symptomatic, treat symptomatically.  If sympathomimetics, these patients need to go to the OR.  

Body Stuffers: deliberately ingests drugs to avoid discovery by law enforcement.  Imaging is usually unneccessary due to small amount of drugs.  If asymptomatic, no need for intervention.  Observation is recommended depending on ingestion.  

Special Scenarios:

  • If patient declines treatment, in the absence of intoxication they have autonomy and you can discharge them with police AMA.
  • If patient self reports (not brought in by police), you are not obligated to report them in Ohio.

Clinical Teaching Skills with Dr. Hopson

Steps to improve clinical teaching: 

1. Set a Positive Learning Environment:

  • Ask about goals, but help to shape these goals
  • Force diversification, make sure they are seeing a variety of patients
  • Be accessible to help throughout shift
  • Set student up for success (walk them through procedure prior to entering patient room, rehearsing consult call etc)
  • Remove stigma of being "wrong"

2. Identify Needs of Learner:

  • Ask learner what their strengths/weakness are
  • Know level of training/future career interest

3. Skills to teach to their needs:

  • Direct Observation: see what the student is actually doing
  • Teaching Scripts: microlectures that can be given quickly 
  • Diagnostic Reasoning Strategies: one minute preceptor, aunt minnie, SNAPPS, SPIT

4. Provide Feedback:

  • Safe environment
  • Expected
  • Bidirectional
  • Non-judgmental
  • Behavior based, with clear next steps

More information about this topic can be found in this article.