7/11/19 Conference Summary: How to approach the year: Be The Magician Be the doctor you would want taking care of yourself and your family. Make the choices that write your story the way you want it. Results and performances that appear magical are come from a mastery and hidden skill. This mastery is earned from intense dedicated study, practice and execution.
Practice how you plan to perform. We don’t rise to the occasion but fall to the level of our training.
Perform like a professional, play nice in the sandbox and learn how to handle in the moment stress
Roll up your sleeves and be ready for things to get weird. Growth happens out side of our comfort zones.
Mind of the Resuscitationist Lecture - emcrit.org emcrit.org This lecture was from the final day of SMACC 2013. It was based on a case I saw at Janus General Hospital. In the lecture I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet ...
Learning How to Learn Learning that is active may be uncomfortable in the moment, but leads to stronger retention. Pay attention, Make efforts to encode the information, practice remembering the information at spaced intervals:
Building the “Perfect” Curriculum - REBEL EM - Emergency Medicine Blog rebelem.com I was asked to give a talk at ACEP 2018 on Building the Perfect Curriculum and given 25 minutes to make this happen. As you can imagine there is no way the entirety of building a perfect curriculum can be done in 25 minutes nor is there such a thing as the perfect curriculum, as we are always evaluating and modifying our current curriculum.
How to Learn and Teach drive.google.com EM Cases Podcast https://emergencymedicinecases.com/learning-strategies-emergency-medicine/ First10EM Make it stick Summary https://first10em.com/making-it-stick/ Building the perfect Curriculum: Rebel EM https://rebelem.com/building-the-perfect-curriculum/ Procedures/Deliberate Practice Skill...
Foundations/Small Groups: Flipped Classroom model, do prep/review of provided resources before coming. Conference time will be used to active learning.
Procedure labs: about once a month but will also be mixing in throughout small group sessions. If you have a particular skill or scenario you want to cover let us know.
Rosh review questions: Will be assigned small amounts post foundations that should cover concepts learned in that session (see above about retrieval practice/spaced repetition)
Get a to do list and calendar doesn’t have to be fancy but get ideas/tasks/appointments out of your head and into something you will look at. Keep your brain space free for more important high level things.
Use podcast apps, RSS feeds to filter through to see only what you want
Have a place to store things you want to review later
Focus on little bits each day rather than trying to binge.
CPT definition: “A critical illness or injury acutely imparts one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s conditions”
Only one doctor can do critical care at one time
Don’t forget to document
Say “Consult” instead of discussion
Health Care Finance
4 models of paying
out of pocket
individual private insurance
employment based private insurance
Medicare Part A: Eligibility
Automatic enrollment at age 65 if eligible
Paid social security for at least 10years
Spouse of the person above
Persons who are totally and permanently disabled may enroll after receiving social security disability for 24 months
People with ALS and ESRD requiring dialysis or transplant are automatically eligible without a 24 month wait
Medicare Part B Eligibility
People who are eligible for Medicare Part B who elect to pay the premium
Some low income people can receive financial assistance
higher income people have higher premiums
>$85,00 for an individual
>$170,000 for a couple
Recheck pt's neurovascular status with a thorough motor/sensory exam
Splint the extremity in question
Make the pt non-weight bearing
Give the pt close ortho follow-up as an outpatient
7/19/18 and 7/26/18 Conference Summary:
EBM: background/foreground question
Background Question: Basic/general question regarding clinical condition, test, or treatment.
Foreground Question: Very specific question regarding specific knowledge to inform clinical action/decision. PICO format: Population, Intervention, Comparison, Outcome
If fracture of the radius or ulnar, must ask self if dislocation:
Vanc/Zosyn doesn’t cover everything. Think about atypicals in cases of PNA with Vanc/Zosyn
Perspective from the inpatient side: giving Vanc/Zosyn can be problematic if culture not obtained yet: some examples include Bone Biopsy
IVDU Abscess – no need for culture, unless bacteremic.
Bilateral cellulitis does not exist - more likely venous stasis.
Get an ABG in COPD to answer a question: is this respiratory acidosis acute or chronic?
ABG bicarbonate is calculated. Look at your BMP bicarbonate for the true level.
Chronic respiratory acidosis? Use the 4:10 Rule when patient is acidotic with elevated PaCO2.
The Bicarb will increase 4mmol/L for every 10mmHg elevation in pCO2 above 40mmHg. If it's not chronic... it's probably acute and thus we need to intervene.
We must be experts in interpreting ABGs as it can change our disposition and level of care for patients.
Make a decontamination decision before the patient arrives to your emergency room.
Symptoms: Wet all over (lacrimation, secretions, vomit, urine, stool) + killer B’s: Bronchorrhea, Bronchoconstriction, Bradycardia
Intubation and Ventilation
Wet all over – expect significant secretions Ventilate – like an asthmatic (bronchoconstriction) Permissive Hypercapnia: Low Rate, Low TV, Low PEEP, FiO2 Titrate Advanced: Avoid High Plateau pressures, Hi Inspiratory Flow Rate
“Atropinize” your patient to smoke out the killer B’s. Atropine 1mg, 2mg, 4mg, 8mg... Pralidoxime 2-PAM 1-2g. Benzos if seizures, no AED.
Alcohol Withdrawal: “Dream Goal – Sedate and NOT intubate” Flavors of Etoh Withdrawal:
Typical withdrawal: hyperalert, shakiness, tremor, elevated HR & BP; 6-8 hours after last drink
Hallucinations: 48hrs to 8 days after last drink, Visual more common than auditory - think large pink lizards
Seizures: onset 12-48 hours after last drink, Grand-Mal.
Delirium Tremens: onset >48 hours after last drink, diagnostic key’s: significant disorientation, autonomic hyperactivity.
Thiamine Deficiency - We miss thiamine it, risk of Wernicke’s
Wernicke’s: ataxia, confusion, ophthalmoplegia (nystagmus more commonly). "When the drunk is gone, the nystagmus should go away." - Dr. Kleinschmidt
Dr. Kleinschmidt treats his ETOH withdrawal patients going fast and heavy: Lorazepam 4mg, 8mg, 16mg, 32mg. Sit at bedside to assess effects. Increase dose every 10 minutes. If prior dose worked, then can repeat dose that worked. CIWA is NOT meant for the acutely withdrawing patient Phenobarbital is old yet novel, read the primary literature to support your opinions
7/5/18 and 7/12/18 Conference Summary:
Tame your Fear List: write down what clinical scenarios you fear most and own them.
Perform mental practice: prepare yourself by seeing that case in your mind before seeing it in real life.
Create Buffer time by having a script with 5 productive tasks to ask your RN and RT to perform when the patient arrives. This can give you time to perform calming techniques. My script is IV, Monitor, O2, CXR/EKG, POC glucose. Perform tactical breathing, say a trigger word, or check your own pulse.
True Ortho Emergencies
When an orthopod, really needs to see the patient tonight at your small community hospital (…cases not to send home with simple follow up)
Definition: In the absence of LVH or LBBB, STEMI is defined as a new STE at the J point in > 2 contiguous leads >2mm STE in men or > 1.5mm in women in leads V2-V3 and/or > 1 mm all other chest or limb leads.
LBBB: New LBBB at time of presentation should not be used as diagnostic of acute MI in isolation. Consider clinical picture and Sgarbossa Criteria:
Inferior STEMI: May be due to occlusion of Right Coronary Artery (RCA) or Left Circumflex (LCx) (depending on heart dominance).
RV Infarction occurs if occlusion of RCA. Get Right sided EKG (see image). STE in V1 is specific, but NOT sensitive for RV infarction. Be cautious about giving Nitro to these patients, consider fluids.
Posterior Infarction may or may not show STE in inferior leads or lateral leads. ST Depression will be seen in V1-V3, for this reason people miss it as a STEMI. Consider obtaining a Posterior EKG.
Diffuse ST depression and aVR elevation: Consider Left main or proximal LAD occlusion. Patient needs cath lab IMMEDIATELY (see EKG below).
- Bicarb ion traps into urine, therefore keep pH alkalemic
If confused and agitated, consider early intubation, hyperventilation (high TV and high RR) to prevent acidosis.
Acidemia leads to increased levels of salicylate in brain. Therefore avoid sedative medications (as they result in hypercarbia) in setting of agitation. Again, consider early intubation.
Level > 100mg/dL is an indication for hemodialysis
http://www.extrip-workgroup.org/salicylates Want to determine if a poison can be dialyzed off? Want the best evidence? This is the website for you – simple, but evidence based. Thank you, Dr. Cao for sharing this valuable resource.
Be safe: do not put patient between you and doorway, always have someone else in room with you, if required to restrain > 5 people to perform safely.
Verbal de-escalate. It is our responsibility, not the RNs.
Orders in Agitation Orderset. Go to orderset and type in "Agitation": Try it. See if you like it.
See highlights from Dr. Roppolo's talk in attachment: