Grand Rounds Recap 10.30.24
/
leadership curriculum WITH drs. jarrell, leenellett and lafollette
Our workforce is changing and our interactions with our colleagues are changing as well. We will review how you may view differences in gender and generation to lead effectively.
Stereotype:
An over-generalized belief about a particular category of people
Meta-stereotype:
When you make an assumption of a member of one group based on a stereotypical view of that type of people
How do stereotypes impact communication
Consults: Difference between consults based on assumptions of medicine vs surgery
Medicine: Assumed to want backstory and details
Surgery: Assumed to want a short, directed question and they will ask more if they need
Generational communication
Older age as a disadvantage: assumed technologic incompetence
Benefit: Knowledge and expertise predict job performance
Reverse ageism: Younger workers perceive more negative age stereotypes and meta-stereotypes
No federal workplace protection for younger workers like there is for older generations
Gender-based communication
Men= Hierarchical
Challenge is accepted
Confidence is praised
Men ritual= “one-up”
Sports metaphors, showing off, teasing
Male: Direct/assertive
Men in meetings: speak more frequently, for more time, more likely to get credit
Women= Communal
Group harmony and likability
Assertiveness is penalized
Female ritual= “one down”
“I’m sorry”
Diminishing compliments, self-deprecation
Indirect/attenuated
Women in meetings may feel: ignored, marginalized, attacked
These are societal stereotypes which are important to know and recognize the individuals in front of you that may or may not fit these and therefore getting to know a persons preferences and communication style is key to effective leadership
Airway Academy WITH Dr. adan
Tracheostomy Basics
Why, when, what, who, where
Why
Airway obstruction
Chronic vent
Dysphagia/aspiration
Airway failure
Prophylactic
When
Immature trach is <7 days
What
A tracheostomy is a connection through anterior neck to trachea, classically done between the 2nd and 3rd tracheal ring
Come in a variety of diameters, cuffed/uncuffed, fenestrated/non-fenestrated. All should have a removable inner cannula
Fenestrated tubes
Good for normal times and for phonation
Can be problematic in emergency situations
Can be a site of buildup of granulation tissue
Case
A patient with a trach comes in for respiratory distress at home, saturating 70%.
O2- everywhere! mouth, nose, trach
Remove inner cannula
Suction, suction, suction
Inflate the cuff
BVM or iGel from above (cuff down)
Exchange trach or place ETTT
Bag the stoma
Intubate from above (if patent)
r1 core content: pneumomediastinum and mediastinitis WITH dr. valles
Anatomy of the mediastinum
Border:
Superior: Thoracic inlet
Anterior: Sternum and costal cartilages
Posterior: Vertebral column
Inferior: Diaphragm
Contents: heart, great vessels, trachea, esophagus, thymus
Pneumomediastinum
Pathophysiology
Air entry through membrane disruption (alveolar rupture, esophageal tear)
Air tracks along the peri-bronchovascular tracts
Can result in subcutaneous emphysema
Can be spontaneous or results from external factors
Spontaneous
Occurs without external trauma or identifiable disease
Common triggers
Coughing, vomiting, asthma, valsalva
Most common in young, healthy individuals (particularly males)
Secondary pneumomediastinum
Trauma: thoracic, rib, esophageal injuries, intubation
Pulmonary disease: asthma, COPD
Infections; necrotizing mediastinitis, gas+bacteria, TB
Presentation
Chest pain, dyspnea, subcutaneous emphysema
Diagnostics
Initial study is CXR, poor sensitivity (26% on PA)
Inconclusive XR should be followed by CT
Management
Secondary: Treatment focuses on underlying cause
Trauma: surgical consultation for injury
Infection: antimicrobial therapy
Primary: Generally self-limiting, close monitoring with follow-up evaluation or serial CXRs
Complications
Tension physiology, compression of cardiovascular structures, hemodynamics
Disposition
Primary: Majority see full recovery in 5 days, outpatient re-eval in 24-48 hours, analgesia with NSAIDs and rest
Secondary: Most cases also often benign, depends on underlying etiology
Mediastinitis
Acute mediastinitis
Bacterial invasion of the loose connective tissue of the mediastinum
Most often comes from direct contamination leading to inflammation of the surrounding structures
Chronic
Prolonged inflammation leads to fibrosis, reducing vascular and airway patency
Clinical presentation
Acute and rapidly progressing symptoms (chest pain, dyspnea, tachycardia, hypotension, febrile)
Diagnostics: Labs and imaging
CT scan is more sensitive than CXR
Esophagram: with water soluble contrast to evaluate for esophageal perforation
Management
All forms of mediastinitis are life threatening until proven otherwise
Broad spectrum antibiotics early
R3 Small groups WITH Drs. Beyde, artiga, and vaishnav
Shoulder Dislocations
Shoulder dislocations are easily diagnosed via ultrasound, with high sensitivity and specificity.
Shoulder reductions can often be performed without sedation using an intra-articular injection.
Both landmark-guided and ultrasound-guided shoulder injections are straightforward and quick to perform.
Femoral and Cervical Plexus Blocks
Fascia iliaca block:
Effective anethesia for isolated femoral fractures and complex anterior thigh laceration/abscesses
Achieved by injecting up to 150mg (3mg/kg max) of Ropivicaine around the femoral nerve
Superficial cervical plexus blocks:
Effective for IJ central lines, clavicle fractures, and earlobe/submandibular
Achieved by injecting 10-15cc Lidocaine under the posterior margin of the sternoclidomastoid.
Use in-plane needle technique for both these blocks and check for hydro-dissection before injecting your anesthetic!
Facial Anesthesia
Facial nerve blocks can provide anesthesia larger areas of the face without distorting anatomy as can sometimes be an issue with local injection.
Common nerve blocks and videos can be found on https://www.tamingthesru.com/regional-anesthesia
