Grand Rounds Recap 8.17.17

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R3 TamingtheSRU: Drowning injuries with Dr. Harrison

The Case
Elderly male fell off ladder into pool and submerged for about 60 seconds, ESRD with dialysis this morning, bystander rescue breaths, oxygen saturating in the mid 80's on a NRB, EMS noted some myoclonic jerking, recently started work up for "spells"
Physical Exam: GCS 4/5/5 = 14, increased WOB, hypoxic
Labs: Consistent with ESRD, normal VBG, trop lightly elevated, EKG with incomplete LBBB
Imaging: CXR with haziness in the left base, HCT with ventriculomegaly versus NPH

Definition of drowning
Process of experiencing respiratory impairment from submersion/immersion in liquid
Epidemiology: 500 K deaths worldwide, 9k in US
Risk factors: age <5 or 15-25, male, African American, coastal states, lower socioeconomic status

Pathophysiology

  • Holding your breath --> hypercarbia --> bodies response is to inhale --> laryngospasm and bronchospasm --> hypoxemia and hypoxic brain injury
  • Pulmonary: Edema --> V/Q mismatch --> hypoxemia -->ARDS

Treatment in the Field

  • Start with rescue breaths
  • C-spine immobilization is probably not necessary without signs of trauma or concerning story (ie head first dive)
  • Heimlich should be avoided (can cause aspiration)

ED Treatment

  • Airway: anticipate persistent laryngospasm and aspiration (consider double suction)
  • Breathing: can trial albuterol for bronchospasm, NIPPV, trend blood gasses, no universal criterial for intubation, put down an OG if intubated
  • Circulation: patient at high risk for cardiogenic shock, can give fluids but no need for 30 cc/kg given liklihood of pulmonary edema
  • Disability: treat like a TBI, balance with ARDS treatment, maintain normothermia, +/- seizure prophylaxis 
  • Disposition: Asymptotic and satting >95% @ 4-6 hours? If so they are likely ok for discharge

Other Therapies

  • No benefit to prophylactic antibiotics, steroids or diuretics
  • Some promising studies using inhaled nitric

R4 clinical Soapbox: A History of Medicine with Dr. Teuber

Influential Physicians
Hippocrates: first physician that separated medicine and religion, defined what a physician should be, described finger clubbing associated with pulmonary disease, created a bench for setting bones
Galen of Pergamon: idea of four humors (blood, yellow bile, black bile and phlegm), invented vascular access, used monkey and pig dissections to begin studying anatomy, differentiating sensory and motor neurons
Andreas Vesalius: granted the ability to perform public human dissection, developed the first atomic plates, discovered the modern voice box
Elizabeth Blackwell: first female to graduate from Geneva Medical College, started a hospital for indigent women and children in NY and then went on to found The Medical College of London for Women

Famous Inventions
Stethoscope: Invented in 1819 as a way to listen to women's heart sounds from a distance
Seldinger technique: Discovered the idea of a finder needle and passing a wire to obtain vascular acess, original, technique was to put needle through the back wall and withdraw until you get flash, what we do now is a "modified seldinger technique"
Sedation and analgesia: Began with opium for pain control then moved to nitrous oxide and finally diethyl ether first used in 1846 which revolutionized surgery

Shift Mentality with Dr. Hill

Case 1: After having been out of the the department in 2 months your first shift back is also your first shift at a new site

  • Plan on getting there early, ask questions, getting the lay of the land so that you're comfortable 

Case 2: After a stretch of nights and facing your last night, the prior shift was particularly difficult. What can you do to prepare yourself for your last shift when you wake up "grumpy?"

  • Do something to get your mind off that last shift, identifying your feelings and why you feel that way
  • Identify a goal for that shift to help get rid of distractions and drive your internal motivations of the shift ahead. This could be improving upon something that did not go well the night before
    • When setting a goal consider how you are going to measure success or obtain feedback
    • Stretch Goals: Specific, measurable, achievable, realistic, timeline
  • Mental Rehearsal: Thinking through the potential situations you may face and then brainstorm what your plan is each of those situations, visualize yourself succeeding in that scenario
    • Consider mental rehearsing rarely done procedures either en route to a shift or immediately prior to performing that procedure

Case 3: Taking turnover on Sunday morning after an extremely busy night with a waiting room and several procedures to do

  • Task prioritization
  • Setting goals for your team with discrete time points 
  • Starting the shift with a positive turn over "Thank you for being here" vs "Go home, today's going to be terrible"

Case 4: Middle of a 12 hour shift and it's very busy. You go into a new patient room and they read you the riot act for not caring about their pain

  • Each patient deserves their time despite what is going on in the department
  • Customer service recovery with an apology or just a moment to listen
  • Expectation management

Case 5: Staying late after a busy shift knowing that you need to be back early in the morning. What can you do to decompress after a shift while still getting rest?

  • Task re-direction (TV, reading, exercise, etc)
  • Support system / talking to someone not medical 

The Thirds Mentality
Consider breaking up shift in halves or thirds
First 1/3: "Cleaning up Turnover"

  • Keep turnovers in mind since it's easier to neglect these patients as you have not seen them primarily
  • Go see them at turnover as this gives you some ownership over their care
  • Find disposition

Second 1/3: "Maintenance"

  • Put your nose to the grindstone
  • Time to focus on  your personal goals for the shift

Final 1/3: "Turnover Preparation"

  • With every new patient you see thin "is this patient is going to be turned over?" 
  • If so try to put a plan in place and finish documentation 
  • If you keep up with your tasks and documentation your effort in the moment is higher but your total shift effort will be decreased