Grand Rounds Recap 06.02.21

Attending Case Follow-Up:Nec Fasc - Attending Case Follow-Up: AMS - Attending Case Follow-Up: Evan’s Syndrome - R2 CPC - Quality in Operations Series - Gathering Sensitive Information - R3 Taming the SRU - R4 Capstone


ATTENDING CASE FOLLOW-UP WITH DR. KNIGHT

Female in her 60s with right gluteal abscess s/p I&D and packing who presents with continued pain. Physical exam is largely reassuring, abscess near but does not involve the anal verge. Rectal exam reassuring. Labs, IVF, pain medications, and antibiotics ordered. She felt improved afterwards and was discharged with prescriptions. Walked out of the ED. Presents again in 3 days and arrests in the ED.

Trust but verify - there is a fine line between providing learner autonomy and having enough supervision to avoid patient misses or harm. Find and welcome this balance.

Double and triple check labs for patients before disposition!!

Fear the dirty dishwater drainage.

Female in her 30s with recently confirmed IUP in the OB clinic presents with RLQ abdominal pain. Bedside transabdominal ultrasound demonstrated free fluid in the pelvis and RUQ. Consult placed to gynecology and acute care surgery. As plans are being made she becomes more hypotensive and is taken urgently to the OR. Confirmed cornual ectopic pregnancy.

Trust but verify - trust your clinical gestalt and concern. Relay this concern to your consultants and stand your ground if you believe a particular diagnosis should be ruled out/an intervention should be concerned. Don’t hesitate to escalate to the attending if needed, but use this sparingly and appropriately!


ATTENDING CASE FOLLOW-UP WITH DR. ROCHE

Male in his 40s with HIV/AIDS brought in by sister for confusion who reports she has been active strangely, unsteady, and confused for the past 2 days. Has been complaining of a headache and photophobia without fevers or vomiting. Possible history of meningitis. Exam is notable for cachectic man with temporal wasting, unsteady gait. Old medication list includes ART, Bactrim, fluconazole, nystatin mouthwash. CXR, UA, CT head w/wo negative. 

Remain objective about whether a procedure is needed

  • If this were the only patient in the department, would I do it?

  • If I could get someone else to do it (R2), would I do it?

  • If this were my family member, would I do it?

  • Tomorrow, will I wish I had done it?

  • CAVEAT: we have a responsibility to each person who presents to the ED - to see them, to move them through so that other patients can be seen

Lean into the procedure

  • Just get it done, quiet moments are rare

  • Avoid the emotional and intellectual drain of a pending procedure

  • Harness the post-procedure high

Versed and a long needle later...opening pressure is 45cmH20. Labs then result with platelet count of 18. 

Always take a minute, don’t rush the prep - be safe

If you rush and aren’t sterile, but honest in your documentation

If you screw up don’t hide it...this will crush you

Testing for Cryptococcus:

  • Sensitivity of serum antigen (CrAg) is close to 100% but may remain positive for years after disease

  • LP evaluates for elevated ICP and other causes of meningitis/encephalitis (may be normal CSF appearance ¼ of the time)

Thrombocytopenia and HIV/AIDS

  • Not uncommon finding at presentation

  • Up to 40% occurrence in advanced AIDS

  • Often improves with initiation of ART

Hospital course: patient received Amphotericin B and flucytosine IV. Serial LPs x5 with improved function and mentation but discharged to nursing facility after 2 weeks of inpatient. Discharged on fluconazole treatment for 8 weeks and restarted ART at 1 month.


ATTENDING CASE FOLLOW-UP WITH DR. FREIERMUTH

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Female in her 20s with lightheadedness, worse with standing up, who reports heavy vaginal bleeding for the past 4 days and requires changing a super tampon every 2-3 hours. These symptoms are not consistent with her normal menstrual cycle, she is not sexually active. She also noted petechiae on bilateral feet and ankles with pale skin. ROS positive for general malaise, palpitations, slight headache, popped a pimple yesterday and her face bled for hours. 

Differential includes: common things being common (ectopic pregnancy, fibroids, PCOS); petechiae (infection, autoimmune); trauma

Physical exam notable for tachycardia to 110s, scattered petechiae to bilateral ankles most notable around sock line that extends to dorsum of feet. Labs notable for hgb 7.7, plt 3, total bilirubin 3.5, INR 1.

ITP vs. TTP vs. DIC

Head CT negative, consulted hematology and intensivist. Given concern for hemolytic anemia +/- ITP, plan is for solumedrol 60mg, IVIG to start upstairs, and to avoid transfusion since she is not actively bleeding. Admitted to ICU.

Evans Syndrome

  • ITP plus autoimmune hemolytic anemia

  • Antibody destruction of blood cell lines

Discharged 6 days later with platelet count of 74 and a prednisone taper. At follow up she is noted to have CD4 25 with negative HIV. Has undergone extensive genetic and autoimmune testing without underlying cause revealed.


R2 CPC WITH Drs. frankenfeld & hill

Male in his 30s with PMH of depression who presents with 1 hour of nausea, vomiting, and 6/10 periumbilical abdominal pain without radiation. He does have a profound urge to defecate. Three episodes of NBNB emesis, no fevers but feels sweaty. Has an upcoming divorce with his wife. ROS notable for diaphoresis, palpitations, depression, and suicidal ideation.

Vitals: HR 89, BP 129/90, RR 24, SpO2 100% on RA, T 34.7 axillary (repeat normothermic)

Physical exam: Diaphoretic, ill-appearing and in moderate distress. PERRL. Tachypneic with clear lungs bilaterally. Abdomen is minimally tender around the periumbilical region without guarding or rebound. Mood is depressed. Labs notable for K 3.0, CO2 14, Anion gap 20, Cr 1.39, pH 7.48, pCO2 25, lactate 3, salicylate 3. CBC, LFTs , INR, acetaminophen, ethanol otherwise unremarkable. UA was grossly bloody with proteinuria and positive nitrites (traumatic cath). EKG with no ischemic changes.

Update: Immediately after examining the patient he had a large bowel movement of orange diarrhea. Had an episode of hematemesis of ~500cc and became hypotensive. Taken to the SRU and repeat VBG notable for pH 7.12 / pCO2 46 / HCO3 15 / base deficit 14.2. EKG with A.fib without RVR.

...and then a test was ordered…


[quick interlude with some attending knowledge bombs]

Referred abdominal pain

  • Epigastric = celiac axis

  • Periumbilical = SMA axis

  • Lower abdominal = IMA axis

What organ systems are affected?

  • GI

  • Cardiovascular

  • Metabolic

  • Renal

What can affect all these systems and has an acute dynamic process?

  • Toxic, metabolic

What did they take? What could they have taken (access to which medications)?

Currently on albuterol inhaler, loratadine, sertraline

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When did they take it? Are they manifesting a toxidrome?

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Not particularly…

MUDPILES: methanol, iron, lactic acidosis, ethylene glycol, salicylate

Iron overdose

  • Rare cause of OD in adults

  • Stage 1 (0-6h) - hematemesis/GI bleed with caustic ingestion and lethargy

  • Stage 2 (6-12h) - symptoms improve

  • Stage 3 (12-48h) - liver failure, coagulopathy, ANT, lactic acidosis, shock

  • Stage 4 (4-6wk) - gastric scarring if you survive

Toxic alcohol overdose

  • Propylene glycol - organic anti-freeze technology

    • Hyperosmolality

    • AGMA

    • Renal failure

    • Hypotension, seizure, coma, death

  • Ethylene glycol - inorganic anti-freeze technology

    • Hyperosmolality

    • intoxicating/inebriation

    • Dysrhythmias, QT prolongation w/calcium oxalate deposition and hypocalcemia

    • Renal failure

Salicylate

  • AGMA with respiratory alkalosis

  • Salicylate directly caustic to IG mucosa (GI bleed in 4% of patients who are admitted)

  • Can have associated conduction block abnormalities - atrial dysrhythmia, NSVT, varying heart blocks

  • Can have a delay in detection, especially with enteric coated aspirin


...iron level 797

Patient reports he took 100 tablets of iron. Decompensated and underwent whole bowel irrigation and chelation in the MICU. Had a downtrending iron level and was discharged on hospital day 9.

Formulations

  • Ferrous sulfate - 65mg elemental iron/tablet - is the most commonly used

  • Ferrous gluconate - 27mg elemental iron/tablet

  • Ferrous fumarate - 106mg elemental iron/tablet 

Free iron is toxic → binds to transferrin. 

  • Typically, transferrin is ~20-30% saturated and when ingestions go beyond this saturation you will see the toxic side effects. Also dependent upon total iron binding capacity. 

  • Toxic iron can cause corrosion of GI lumen and cause hypovolemia and hemorrhagic shock. 

  • It also concentrates in the mitochondria and interferes with oxidative phosphorylation - will severely impact anything that uses this (heart, brain, liver).

Dose-dependent toxicity

  • More dangerous in children with smaller doses

  • Asymptomatic with 20mg/kg ingestion

  • 20-60mg/kg ingestion is only GI manifestations

  • 60-120mg/kg will result in cardiac side effects (our patient!)

  • >120mg/kg is a lethal dose

See above for stages of iron toxicity!

Diagnostics

  • Iron level peaks at 2-6 hours

    • Body is great at shifting iron intracellularly, so have a high index of suspicion in the appropriate clinical context if your iron level comes back suspiciously low!

  • KUB as many iron-containing medications are radiopaque

Therapeutics

  • Fluids 10-20cc/kg

  • Chelation: deferoxamine

    • Indications are for >90umol/L, shock, systemic toxicity, AMS, acidosis

    • Dosing: IV 15mg/kg/hr, IM 50mg/kg Q6H...max 6g/24h

    • Pink-tinged urine

  • Whole bowel irrigation with polyethylene glycol solution

    • Insert an NG tube and insert 1.5-2L/hr

  • Bicarbonate for persistent acidosis

Ineffective therapies

  • Activated charcoal does NOT bind iron tablets

  • Dialysis will not eliminate iron alone, but can be used to eliminate chelated iron/deferoxamine complexes


OPERATIONS QI UPDATE WITH DR. D.THOMPSON

How is patient safety relevant to you?

  • Emergency medicine = high risk for patient harm

  • Majority of safety events identified through Midas reports, mortality reviews, codes, word of mouth, etc.

  • Examples: medication errors, patient falls with injury, patient assaults, delays in care or delays in diagnosis, complications

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Historically at UC each department had their own approach (M&M, case reviews)

  • Very siloed

  • Focused on individuals

  • Try to do the right things

Current and future state

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  • Unified approach to patient safety

  • Focus on systems rather than individuals

  • Make it hard to get things wrong

  • Multiple patient safety models have been created by the Joint Commission, the National Quality Forum, and the WHO

  • UC Health chose a model for patient safety called Healthcare Performance Improvement, a division of Press Ganey (1100 health organizations who use this model as well)

  • Identify events from various sources and funnel/screen these events based on organization or individual culpability and level of harm to the patient - output is a classification system


IMPROVING HISTORY TAKING: GATHERING SENSITIVE INFORMATION WITH DR. FREIERMUTH

Importance of history 

  • Adds context to the presentation

  • Guides your differential - 70% of diagnoses can be made by history alone

  • Minimizes unnecessary testing

  • Reveals behaviors that contribute to health which may need modification

First impressions matter

  • Clearly introduce yourself and your role on the care team (not everyone knows what a resident or attending is)

  • Sit down if possible (it’s less intimidating than standing over the patient and patients will perceive this as spending more time with them)

  • Try your best to let the patient talk (the average physician interrupts a patient after 18s)

  • Make eye contact (if charting while in the room, share your screen with the patient or make sure you are focused on them while asking questions)

  • Body language of a patient can add to your information gathering

Ask the patient about his/her/their preferred name

  • Tell me how you would like to be addressed…

  • Who do you have here with you in the room? Allow them to answer and ask about the relationships if only a name is stated. How are you related or how do you know each other? Is it OK if we discuss your complaint and medical history in front of said person?

Emergency Department visits are exhausting

  • People are here because they don’t feel well

  • Repetitive questions is frustrating - go in as a team when possible

  • Summarize what you have learned from the nurse/nursing note/EHR and then expand from there 

  • Share wit the rest of the care team if a patient shares a preferred name/pronoun with you that is incongruous with EPIC 

EHR - help or hindrance?

  • Information may not be accurate - must be verified

  • We are the head of the care team and should ensure PMH, surgeries, and social histories

Develop a system

  • Asking the same questions the same way each time ensures you don’t forget

  • Also decreases bias from assuming certain items won’t apply to certain types of patients

  • One study demonstrated that there is physician variability in history taking in ED chest pain patients (Academic Emerg Med 2006) varying based on gender, race, age, etc.

Framing your questions

  • Open ended vs leading

  • Non-judgmental tone

  • Practice so your own discomfort isn’t obvious

  • Some preface with explanation for why they are asking certain questions

Key portions of history

  • PMH - is the problem today new or an exacerbation of underlying disease

  • PSH - missing/altered organs

  • medications/allergies

  • Family history

  • Social history - living situation, substance use, sexual practices

Language for questioning

  • Where do you live? Who lives with you?

  • Do you ever have difficulty getting enough food to eat?

  • How much do you smoke per day?

  • How often do you drink alcohol/? How much do you typically drink on those days? Clarify use - beers come in different sizes and very different alcohol content

Questioning continued

  • Do you use any type of drugs, such as cocaine, marijuana, or heroin? Any pills that aren’t prescribed to you? Do you use needles to inject drugs? Avoid words such as illegal or illicit!

  • How many sexual partners have you had in the past 6 months? Do you have sex with men, women, or both? Do you use condoms or other barrier methods? How often? Sex can include vaginal, anal, oral, and use of other objects

Don’t forget about harm reduction

  • Discussion surrounding safer sex practices

  • Need for testing/treatment of partners when STI is a concern

  • Safer use of drugs

    • Don’t mix drugs, use with someone who can call for help if needed, clean needles and syringe exchanges, access to naloxone stocked in omnicell!

  • Majority of physicians and APPs have an X waiver to prescribe buprenorphine

ED resources

  • Early intervention team

  • Substance abuse team

  • Peer counselors offer their own experience

  • Referral to treatment


R3 TAMING THE SRU WITH DR. PULVINO

Male in his 50s with LKN 22:30 (2 hours PTA). Stroke with patient flaccid on the left and simultaneous ST elevations in multiple leads.

Stroke + STEMI?

  • Aortic dissection

  • LV aneurysm w/ embolic stroke

  • Septic emboli from endocarditis

  • STEMI is a red herring (pericarditis, old EKG findings, etc.)

Patient denies chest pain or shortness of breath, in no discomfort. Definitely having a stroke with left facial droop, left upper extremity weakness, left-sided neglect and mild dysarthria. CT head, CTA head, neck, chest, abdomen/pelvis ordered. Glucose 141. No ICH and stroke team is paged. CVICU team also paged given ST elevations on pre-hospital EKG - cath lab not activated due to lack of symptoms. 

Radiology calls and notes a complete R M1 occlusion. EKG in ED does not demonstrate STEMI. Bedside echo performed by CVICU fellow demonstrates mitral valve vegetation with grossly normal LV function. Concerned about endocarditis at this time, and infectious work up is initiated in addition to antibiotics ordered. Patient receives aspirin 325mg. 

Stroke team does not recommend tPA given concern for infectious endocarditis, and the patient goes to neuro IR. TICI 2b reperfusion achieved, NIH remained 9 (from 10 on ED presentation). Blood cultures positive for E.faecalis. Has a complicated hospital course 

Infective endocarditis

  • Diagnosis - Duke criteria

  • Management

    • Blood cultures to target abx therapy

    • Antibiotics should be administered empirically

    • Supportive care

    • Consults to cardiology and CT surgery for possible valve replacement

  • Stroke from infective endocarditis

    • The brain is one of the most frequent sites of embolization in left-sided endocarditis

    • Duke criteria are often no present or noticed

    • Thrombolytics are contraindicated, but thrombectomy is an option

    • Antibiotics decrease risk of embolization

    • Antiplatelets and anticoagulation are controversial

  • STEMI in endocarditis

    • Very rare, mechanism is usually embolic

    • Thrombolytics = big risk of bleeding

    • PCI can be helpful

    • Case report of nonobstructive STEMI with endocarditis and ICH

  • Takeaways

    • No thrombolytics for endocarditis

    • Treatment is fast antibiotics and individualized supportive care

    • Take a full history (and get a full set of vital signs!)

    • Ultrasound is your friend

    • Don’t be afraid to call for help


R4 CAPSTONE: LESSONS LEARNED ALONG THE WAY WITH DR. MAND

  1. Learn from your mistakes

    • Intellectualize the criticism

    • Open, non-biased communication

    • Self-forgiveness

    • Become an expert/prevent recurrences

  2. Sometimes, despite your best efforts, good people die

  3. How you perceive yourself may not be how others view you

  4. When loved ones get ill, don’t be their doctor, be their support. Be their family.

  5. Imposter syndrome is

    • “The internal belief that one is not intelligent or successful despite a history of high achievement”

    • “a collection of feelings of inadequacy that persist despite evident success” 

    • Don’t let imposter syndrome hold you back

    • Does not necessarily correlate with low self-esteem or lack of self-confidence

    • Be self aware, reframe your mindset, recognize your own value, seek support

  6. Progress at your own pace

  7. Embrace your emotions

  8. Find your people

  9. Focus on the GOOD you do

Grand Rounds Recap 06.02.21