Grand Rounds Recap 11.16.22


R4 Capstone - Leading from the front WITH dr. Ijaz

  • Leaders deal with change

    • Setting direction involves creating a vision

      • Requires big picture thinking and shaping purpose of organization

    • Align People

      • Share the why you do what you do

      • Be consistent in your messaging

      • Be on the front line leading by example

      • Share your vulnerability

        • Leaders reveal their weaknesses so followers can establish trust and collaborate

        • Shows that you are genuine and approachable

  • Managers plan and budget

    • Planning and budgeting directly complements direction-setting.

    • This is how you develop strategies to accomplish your vision

    • Organize and hire individuals to complete roles that fit within the larger mission

  • Emotional Intelligence

    • Self-awareness

      • Know one’s emotions, strengths, weaknesses, drives, values and goals

      • Self confidence

      • Self assessment

    • Self regulation

      • Controlling or redirecting disruptive emotions and impulses

      • This is where the concept of “seek first to understand” comes into play

    • Empathy

      • Considering others’ feelings, especially when making decisions

      • This is when you see your colleague deal with a tough case. You reach out to cover their patients while they take a few moments for themselves

    • Motivation

      • Being driven to achieve for the sake of achievement

      • Passion for the work itself and for new challenges

      • Unflagging energy to improve

      • Optimism in face of failure

    • Social Skills

      • Managing relationships to move people in desired directions

      • Effectiveness in leading change

      • Persuasive

      • Networking

      • Building teams


Thoracic Outlet Syndrome WITH dr. stothers

  • Anatomy

  • Thoracic outlet bordered by clavicle, first rib, middle and anterior scalene muscles

    • Contents include subclavian artery, subclavian vein, three trunks of brachial plexus

  • Pathophysiology

    • Neurovascular compromise from compression of vascular structures or brachial plexus

      • Tumors

      • Anatomical variants (cervical rib, duplication of scalene muscles, hypertrophy of muscles)

      • Trauma (microtrauma from repetitive use vs. macrotrauma from blunt injury)

  • Clinical Presentation

    • Depends on the structures that are compressed

      • Brachial plexus (95%)

      • Subclavian vein (4%)

      • Subclavian artery (1%)

      • Thoracic duct (possible, but rarely reported)

    • Brachial plexus

      • Shooting/tingling/burning pain in the neck/shoulder, arm or hand, often not in a neurologic distribution

      • Present in professional athletes, violinists

    • Subclavian vein

      • Intermittent compression (McCleery Syndrome) - pain, redness and swelling

      • Chronic compression (Paget-Schroetter Syndrome)

        • Central venous thrombosis

        • Associated with young athletes

    • Subclavian artery

      • 5 P’s: pain, pallor, paresthesias, pulselessness, paralysis

      • Often asymptomatic until repeat compression leads to proximal aneurysm formation -> thrombus development -> distal arterial emboli

  • Diagnosis

    • Physical exam

      • Upper extremity stress test

        • To diagnose neurogenic thoracic outlet syndrome, must perform for 3 minutes

    • Ultrasound

    • CXR for cervical rib

    • CT angiogram

    • Anterior scalene intramuscular block, may indicate neurogenic TOS

  • Treatment

    • Surgical debulking

    • Lifestyle modification

    • Anticoagulation

    • Anterior scalene intramuscular block


Litigation Stress WITH Dr. Gita Pensa

  •  Emergency physicians are unprepared when it comes to litigation

  • Stressed defendants make more errors

  • Prepared defendants are better defendants

  • This will happen to most of us

  • Silence perpetuates stigma

  • It is the right thing to do

  • Good news

    • Less than 10% of cases go to trial

    • Punitive damages/personal asset losses are very rare

    • Rates of paid claims is down by 55%

  • Bad news

    • 75-90% of us will be named at some point during career

    • Annually 7.4% of all physicians are sued

    • Threat of targeting personal assets is an increasingly used tactic

    • Highest payout states: NH, NY, NJ, RI, MA, IL, PA

  • The adverse event in medicine 

    • Event leads to outcry, then denial, then intrusion, “working through”, and then completion

    • Can lead to acute stress, maladaptive behaviors, personality constriction, PTSD

  • Why litigation is difficult for physicians:

    • Physician Psychology

      • Perfectionism

      • Takes personal responsibility

      • Used to being in control and used to being the expert

      • Ego: changing habits of thought

      • Thinks rationally and scientifically

      • Fairness, justice, altruism are all highly valued

    • Culture

      • Asking for help may be sign of weakness

      • Emotional distress can be viewed as weakness

      • Self-sacrifice is the standard

    • Physician naivete

      • Little teaching or discussion

      • No visible role models

      • Expect law to work like medicine

      • No understanding of strategy or skills

      • Blind to deliberate emotional manipulation

      • Takes the process personally

    • System Design

      • Plaintiff's attorneys are well versed in physician psychology and their job is to win

      • Judge and jury have no medical expertise

      • Physician weaknesses exploited systematically

      • Leverage guilt, emotion and naivete

      • Experts: no standards, no consequences

  • Litigation Stress

    • Stress incurred by physicians after involvement in a malpractice suit

      • Common themes and reactions:

        • Fear of repercussion/judgment

        • Shame

        • Imposter syndrome

        • Anger at unfairness, experts, lack of control

        • Guilt and self-accusation

        • Obsessive recounting of events

        • Disillusionment with medicine

  • Actions to take if served:

    • Do not tell anyone but your attorney the details of the case

      • Possibly spouse, peer review, “hypothetical” cases

    • Do tell supportive friends and family that you have been named and how you are coping

    • Do seek out colleagues or other physicians who have been through the process

    • Do get a book or visit professional society resources

      • Adverse events, stress and litigation (Sara Charles MD)

      • When good doctors get sued (Angela Dodge PhD)

      • How to survive a medical malpractice lawsuit (Ilene Brenner MD)

  • Malpractice Stress Syndrome

    • Continuum with litigation stress syndrome

    • Increased physical symptoms

    • Severe depressive or anxiety symptoms

    • Inability to perform duties at work

    • Substance abuse

    • Suicidality

  • Litigation is a long process, and must be viewed as chronic stress with acute exacerbations

    • We should provide ongoing support for colleagues who may be experiencing litigation

    • Process should not be hidden

    • Seek support – process should not be ventured in isolation

  • “The science… tells us that stress is most likely to be harmful when three things are true:

    • You feel inadequate to it

    • It isolates you from others

    • It feels utterly meaningless and against your will”

  • What can we do: talk, learn, find help, reframe, give help


Trial vs. Settlement WITH dr. Gita Pensa

  • Wong KE, Parikh PD, Miller KC, Zonfrillo MR. Emergency Department and Urgent Care Medical Malpractice Claims 2001-15. West J Emerg Med. 2021;22(2):333-338. Published 2021 Feb 15. doi:10.5811/westjem.2020.9.48845

    • 15 years, 6779 claims

      • 65.9% dropped, withdrawn or dismissed

      • 22.8% settled

        • Average settlement $297,709

      • 7.6% went to trial - defendants prevailed 92.6% of the time

  • “True malpractice is settled”

    • Most cases don’t actually involve malpractice

    • Most cases that go to trial are defensible

  • Criminal vs. Civil Litigation

    • Anyone can file a lawsuit in civil court

    • Burden of proof is different

      • Civil = preponderance of the evidence

      • Criminal = beyond a reasonable doubt (higher bar)

    • What's at stake:

      • Civil = money

      • Criminal = jail, probation, fines, community service

  • Considering settlement offers

    • Speed 

      • Can spare you months to years of preparing for trial

    • Certainty

      • If case goes to trial, cases are decided by judges/juries without medical expertise

    • Disadvantages:

      • Physician

        • Reported to the NPDB

        • Licensure and privileges disclosures

        • Feels like admission of wrongdoing

      • Insurer pays money

      • Plaintiff loses a chance for a big trial payout

  • Insurer Perspective

    • Wants to support the doctor

    • They are a business = responsibility to make smart financial decisions

    • Trial is expensive

      • Attorney and expert billable hours

      • Would a settlement make more sense and be cheaper?

      • How likely is a large judgment against them at trial

      • What other losses have we had recently?

    • “Don’t feed the bears”

      • Can’t settle everything

  • Physician Perspective

    • Emotional stance

    • Justice vs. anxiety

  • Plaintiff’s Attorney Perspective

    • Settlements are bread and butter

    • Trial is expensive and stressful

    • How likely is a windfall?

  • Settlements can occur at any time, including during trial at any point prior to verdict

  • True malpractice is settled

    • However, settling does not always mean malpractice occurred (just the best decision among bad choices)

  • “Consent to settle” and “hammer” clauses

    • Consent to settle clause = doctor has the ability to decide whether or not a case can be settled

    • Hammer clause = if you decide to forego settlement and take the case to trial and lose, you are responsible for verdict in excess of settlement offer

  • Preparing for trial

    • Once a trial date is set, talk to your attorney about a prep plan

    • Trial dates are subject to change

    • Attorney will instruct you

    • Know the sequence of events

      • Jury selection and ‘voir dire’ (examining the jurors)

      • Opening statements

      • Plaintiff puts on case first, then rests

      • Defense puts on case, rests

      • Closing statements

      • Judge “charges the jury”

      • Deliberation and verdict

    • Know your deposition testimony

    • Know your role

      • Testifying is different from deposition

        • Talk more

        • Explain more fully

        • Educate the jury

        • You are supposed to be a ‘fact’ witness

        • Within that context, teach the medicine

      • Connect with the jury

      • Demeanor matters

    • Skill set and mind set

      • Learn to hold composure no matter what

      • Be attentive to word choice and tone

      • Be mindful of body language, positioning or any nervous habits

      • Be knowledgeable, but not egotistical or arrogant

      • Learn about common questioning traps and how to avoid them

      • Know the rough spots and how you will handle them

      • Learn to evade being pigeonholed

  • Take home points:

    • Connect with the jury on a human level

    • Let your concern and care for patient and shine through

    • Educate the jury and make them understand your side of events

    • Stay calm and composed, no matter what

  • The jury should come away wishing you were their doctor

  • The outcome does not rely on you alone

    • Judge decisions and attorney performance

    • Where the case is tried

    • Performance of experts

    • Co-defendants

    • Makeup of jury

    • Plaintiff optics

  • Control the things you can

    • Skill set

    • Mindset

    • Prioritizing your own health   


Air care Grand rounds WITH drs. winslow and goff

Impella and Transfer Training - Dr. Saad Ahmad

  • Cardiogenic shock is a spectrum and subtle signs (rising Cr, poor extremity perfusion, rising transaminases) must be appreciated and may be present without hypotension

  • Approach at the bedside

    • Pulse pressure (SBP-DBP) < 25% of SBP indicates low cardiac output

    • Echo (contractility, PA pressure, valve assessment, dynamic obstruction, device depth, effusion)

    • EKG

  • Impress Trial - 2016 RCT comparing IABP and impella on 6-month mortality

    • No difference

    • Small sample sizes

    • Sick population (mean pH 7.15, lactate 8, post-arrest patients with cardiogenic shock)

  • RV support

    • TandemHeart with dual lumen cannula

    • Impella RP

      • Femoral access

  • LV support

    • IABP

    • Impella

      • Typically femoral access, sometimes axillary

    • Tandem Heart

      • Femoral artery and femoral vein access

      • Inflow cannula in LA (venous percutaneous access through ASD), blood returned into aorta

    • ECMO

  • Impella Configurations

    • Impella RP for right sided support

    • Impella CP for left sided support

    • Impella 5.5 - axillary cutdown for left sided support

    • Bipella - Impella CP or 5.5 + RP

    • Ecpella - ECMO + impella for LV unloading

  • Things I need to know when picking up an impella patient on Air Care:

    • Clinical indication

    • Hemodynamics before and after support device

    • Access (number of sticks) - ask if access was easy

    • Groin appearance

    • Sheath depth

    • Sheath (peel away or repositioning sheath)?

    • Is the sheath secured?

    • Tuohy Borst Valve secured? (White twistable valve proximal to the blue T piece that is sutured to skin - will prevent catheter from slipping within sheath)

      • If not secured, impella will move

    • Distal pulses (pre and post impella)

    • Anticoagulation: ACT, infusion

      • Cangrelor much more potent platelet inhibitor than Brilinta 

    • Urine color

  • Patient considerations:

    • With femoral access, do no raise head of bed higher than 30 degrees 

    • Use knee immobilizer

    • Assess access site for bleeding and hematoma

    • After confirming security of access site, position impella plug to allow easy access during transport in the event of a “air in purge” alarm

    • Be careful not to pull on the impella catheter when transferring a patient from one bed to another

    • Monitor distal pulses

    • Do not use alcohol products on any part of impella products

    • Make sure fluids are hanging higher than the purge cassette

  • If you must perform CPR, turn the impella down to P-2

    • If you need to defib, do not change impella settings

  • If you get an “impella stop” alarm, it is not functioning and you may need to start inotropes

  • Waveforms:

    • Placement signal = similar to art line waveform (similar pressure)

    • LV pressure is estimated, pay attention to EDP

    • Motor current (difference between inlet and outlet), must be pulsatile

    • Flow displayed in bottom left

      • Top and bottom numbers (systolic and diastolic flows) should be at least 1L apart 

    • Purge system (flow and pressures) next to the impella flow numbers

    • Cardiac output and power output numbers next to purge system numbers

  • Alarms:

    • Suction:

      • Reduce P level

        • Decrease until suction alarm breaks

      • Filling level and volume status

        • Can see negative diastolic pressure on LV pressure reading

      • Verify impella position

ECMO Logistics

  • Expect increasing volumes of ECMO transports in the coming years either by Air or Ground with UC and The Christ as receiving; also long distance transports out of Cincy to other centers for transplant (Cleveland, Detroit, etc)

  • Crew configuration based upon receiving - ECMO nurse specialist + flight crew if going to Christ; perfusion + CCAT + flight crew if UC

  • Eyes on and dedicated handler for ECMO cannulas during any patient movement. 

  • Consider the myriad logistics of the transport including multiple infusions (analgosedation, paralysis, heparin, vasopressors, blood products, antibiotics), ventilator, chest tubes, ECMO cannulas, CVC, PA catheters, A line, Foley - organize perhaps with the lasagna technique of layering devices with blankets 

  • Consider VV vs VA indications and rescue enroute should mechanical support fail.

    • VV - likely on lung rest settings on ventilator and may need to titrate settings; may need to initiate Veletri

    • VA - consider inotropes, vasopressors, preload versus afterload reduction

  • ECMO mounting equipment - all front-line AC stretchers with ECMO bracket to accommodate ECMO shelf. Review images below for anticipated gurney configuration and loading with ECMO moved to floor plate for flight.