Garrett-Hauser/Richard JamesChaplain Religion and Medicine
We discussed the challenges of discussing and respecting religion with patients and their families. The background for this discussion was based on the article: Religion, Spirituality, and the Intensive Care Unit. The Sound of Silence. Balboni, et al. JAMA Intern Med. 2015
Exerpt of Article Review: the authors explore the re-
ligious and/or spiritual thematic content of goals-of-care con-
versations between health care professionals and surrogates
of critically ill patients. Although religion was important to
77.6% of the surrogates, only 16.1% of the conferences in-
cluded any reference to religion or spirituality. Furthermore,
when they did occur, these conversations were initiated by sur-
rogates 65.0% of the time. A health care professional raised
spiritual concepts (eg, spiritual histories) only 14 times (5.6%),
and only 2 of the conferences (0.8%) were attended by a chap-
lain. When surrogates raised spiritual concepts, health care pro-
fessionals’ most common response was to change the subject
to the medical realities at hand. Although empathic re-
sponses were the next most common response, health care pro-
fessionals, in general, “rarely directly addressed surrogate’s
spiritual or religious language.” Only 2 health care profession-
als responded by exploring the patient’s or surrogate’s spiri-
tuality. Notably, for conversations that included religious and/or
spiritual content, various themes were identified, with miracles
being one of several spiritual themes that intersected with medical care
the authors highlight, indicate the crucial need for greater integra-
tion of chaplaincy into ICU care
and for spiritual care education for health care professionals,
including how to integrate
a basic exploration of religious and/or spiritual values into
health care communication.
Our patients and families who face serious illness typi-
cally find themselves in spiritual isolation in the medical set-
ting; their medical caregivers do not hear the spiritual rever-
berations of illness on their well-being and medical decisions.
As with the lonely, falling tree, the reverberations are unde-
niably there. The question remains whether we who care for
dying persons and their families will learn how to be present and listen.
Every spiritual discussion with patients/families is contextual. You have to make an effort to “know thy patient” and “know thy self”. Understanding the patient and your self will help you dialogue about religion. You should try to rise above specific religious boundaries and get to a level of general spirituality. A key is to make your interaction with the patient an experience of benevolent intent toward them.
You can actually express benevolent intent in a pretty short period of time in the ED. As a non-medical example, you can tell even when you interact with a cashier for a even just aminute whether or not they are acknowledging and respecting you as a person.
Recognize when patients and families use their religion in unproductive ways.
An example would be a patient refusing surgery for a gangrenous leg and saying God will heal this leg. You may need to consult a chaplain to help with this type of situation.
A good starter question to discuss spirituality with patients/families would be,
“Is there a particular faith perspective that you use to cope with life’s challenges?”
Harwood comment: If someone expresses that faith is an important part of his or her coping strategy, I would consult pastoral care to help with the case. Chaplain Richard James agreed. The key is to show respect for a person’s faith.
Bamman Traumatic Hand and Wrist Injuries
*Brief Hand Neuro Exam.
*Ever Briefer Neuro Exam. All 3 nerves in one movement.
*Fight Bite Injury. This is a high risk injury. Give IV antibiotics such as Unasyn or Clindamycin/Cipro if PCN allergic. GetX-rays to evaluate for fracture and foreign body. Examine the wound through the full range of motion to identify any tendon injury. Consult Hand Surgery.
We had a discussion about nail trephination. Girzadas suggested doing a digital block or at least discussing options for pain control or making the patient aware of possible pain prior to the procedure. All the other attendings strongly disagreed and felt no digital block was necessary. They felt just warning the patient that they may feel a momentary pain was adequate.
Mark discussed finger tip injuries. All attendings agreed that if the nail is fully intact, don’t remove the nail to go searching for a nail bed laceration. Only remove the nail to repair the nail bed if the nail has already been partially avulsed or disrupted.
*Thumb Fractures There are two syllables in Bennet and the Bennet’s Fracture has two fracture pieces. Rolando has three syllables and has three or more fracture pieces.
*Lunate and Peri-lunate Dislocations. These need Hand Consultation while the patient is in the ED.
*High Pressure Injection Injury is a surgical emergency.
Williamson Study Guide GI
CT is not indicated for uncomplicated pancreatitis.
Pancreatitis is considered severe when there is pulmonary dysfunction.
The most common causes of pancreatitis in order from most to least common: Gallstones, alcohol, idiopathic, hypertriglyceridemia, scorpion bite.
*Epiploic appendigitis is due to torsion or inflammation of an epiploic appendage.
Most common cause of SBO is adhesions.
*Olgilvie Syndrome seen most commonly in elderly patients who are ill, have had trauma or surgery. It usually resolves with NG drainage alone.
*We discussed TXA for Upper GI Bleeding. A quick literature review found a Meta-Analysis showing some evidence of lower mortality in patients who received TXA.
The most common cause of bacterial diarrhea in patients diagnosed in the ED is Campylobacter. Faculty all agreed that probiotics or yogurt with active cultures is a useful management tool for patients with diarrhea.
Elise comment: Pepto-Bismol can turn a patient’s tongue black and can turn their stool black.
Staph Aureus Gastroenteritis: Mayonaise/potato salad is a common buzz word in questions, onset occurs within a couple of hours, patients have mostly vomiting, it is self-limited. Resolves in a few hours.
*Crohn’s vs Ulcerative Colitis
Most common cause of cancer of biliary tree is cholangio (gall bladder) carcinoma.
Alexander EKG Workshop
Ari led the residents thru multiple clinical scenarios of tachycardia with EKG stimuli.
Elise comment: Regular rhythms (both supraventricular and ventricular)are more easily converted than irregular rhythms so initially use 100J for these regular rhythms. Irregular rhythms are more difficult to convert so use 200J inititally.
Pharmacist comment: Procainamide is favored over amiodarone for converting stable V-Tach.
Ari discussed a case of SVT in a patient who was on digoxin and a beta blocker. The patient was given adenosine and then developed an idioventricular rhythm for a short time before she converted to sinus. It was pretty terrifying for a few minutes. This may be a risk in patients on other cardiac meds.
Katiyar/Bonaguro QI Sepsis
Please pay close attention to the Sepsis Guidelines. Document the suspected source of infection. You need to perform/document a repeat physical exam after the patient receives their initial 30 ml fluid boluses.
*Surviving Sepsis Guidelines
To document your repeat exam you need to note the following:
Vital signs, heart exam, lung exam, cap refill, peripheral pulse and skin exam.
In our Cerner system if you type in ..sepsis it will pull up a simple templated note that will draw in the vital signs and then you just need to fill in the physical exam.
Abhi and Sheila comments: Think of sepsis similar to belly pain where you want to get a repeat exam documented in the chart.
The clock does not start toward time targets until there is documentation of a suspected or confirmed infection in the chart or an elevated lactate is identified.