Conference Notes 11-15-2017

Zelkovich      Radiology

Unfortunately I missed this excellent lecture

Walchuk      Pediatric Study Guide

Kawasaki's Disease

 If you think a patient may have Kawasaki's Disease order a CRP or ESR. If the results are high, consider an ID consult or OBS stay.

If you think a patient may have Kawasaki's Disease order a CRP or ESR. If the results are high, consider an ID consult or OBS stay.

 Images associated with Kawasaki's disease

Images associated with Kawasaki's disease

Fever work up

 One reasonable approach to the febrile infant under 3 months.  Some more conservative docs would move the cut-off for full septic workup to 6 weeks.  

One reasonable approach to the febrile infant under 3 months.  Some more conservative docs would move the cut-off for full septic workup to 6 weeks.  

Brian Carlson       Financial Planning

An important way to protect your assets is with an auto liability umbrella policy.  You can get sued for major $'s due to auto accidents or injuries on your property. These types of policies are a cost-effective way to protect your assets. You definitely should purchase as much as you can.

Strategies to protect wealth from litigation are:

1. 401K/403B/Pensions.  These are off-limits to lawsuit damages.

2. Whole life insurance policies or Premanant Life Insurance policies.  These options can have additional tax benefits but they need to be structured properly to provide that benefit. These are to be considered only as long term asset protection strategies. These are off-limits to lawsuit damages.

3. Educational accounts (529 accounts), Not accessible to lawsuits.

4. Irrevocable trust.  Cannot be taken away in a lawsuit but you also cannot get at the money either.

5. Annuities are also a protected class of assets.  But annuities are high-cost and not a great vehicle for most doctors.

6. If you are married, put your house in "tenancy by the entirety" so it cannot be taken away in litigation.  This is inexpensive to do and it protects your house from loss due to medical malpractice or other lawsuits. If you are not married you cannot take advantage of this strategy. 

7. IRA's in the State of Illinois are protected from liability litigation.   If you move to another state it may not be protected, so you have to be very careful about where you put your money.

An important strategy for building wealth is to get $ into tax protected vehicles: Roth IRA's,  permanent life insurance, and educational investment funds (529) are some examples.

You need to get a private disability policy as soon as you can and as early in your career as possible.  This should take priority over life insurance.  This is because the younger you are the less expensive disability insurance is.  The cost goes up 8% every year that you wait.  This added cost is carried forward throughout your career.    Make sure your policy is specialty specific. "True own occupation" policies will pay the benefit if you can't practice EM even if you work and earn income doing physical exams or in another medical specialty.

Do not write prescriptions for yourself!  If you write a prescription for yourself, even if just for zofran or a Z-pack it will disqualify you from getting a disability policy!  The insurance companies see this as a red flag for dishonesty in your health history and risk for future self-prescribing for more serious medications like benzos or opioids.

Traylor     Environmental Emergencies

Capnocytophaga Canimorsus is a bacteria in the oral flora of dogs.  Patients who are asplenic (sickle cell disease patients, patients with prior splenectomies) are at risk for bacteremia and sepsis following dog bite from this organism.  Bacteremia and sepsis from this organism has a 30% fatality rate.

Capnocytophaga canimorsus has been implicated as a pathogenic agent in a variety of clinical conditions such as septicemia, purpura fulminans, peripheral gangrene, endocarditis, and meningitis following dog bites (116, 139, 158, 166, 178, 189). Although fulminant infections with Capnocytophaga canimorsus after a dog bite have been reported for immunocompetent patients (116), it appears that immunocompromised patients (e.g., those who have undergone splenectomy and those with liver disease, etc.) are most susceptible to this type of infection and its complications (139, 166, 178, 189). 

Abrahamian FM, Goldstein EJC. Microbiology of Animal Bite Wound Infections. Clinical Microbiology Reviews. 2011;24(2):231-246. doi:10.1128/CMR.00041-10.

 These pictures demonstrate livedo racemosa from capnocytophaga canimorsus.  Editors note: Highest risk patients are those without a spleen, alcoholics, and other causes of immunocompromise.  Immunocompetent patients however also have gotten this infection.  Consider prophylaxis with Augmentin or Clindamycin for dog bites. 

These pictures demonstrate livedo racemosa from capnocytophaga canimorsus.  Editors note: Highest risk patients are those without a spleen, alcoholics, and other causes of immunocompromise.  Immunocompetent patients however also have gotten this infection.  Consider prophylaxis with Augmentin or Clindamycin for dog bites. 

Posterior shoulder dislocation

 Y view shoulder x-ray showing the humeral head not in contact with the center of the Y and posterior to the scapula. 

Y view shoulder x-ray showing the humeral head not in contact with the center of the Y and posterior to the scapula. 

Walsh PharmD   Lecture on Hypertensive Emergencies

Aortic emergencies: Shoot for dropping the systolic BP to 120 and HR to 60.  You want to lower the shear stress on aortic wall.  Reach for esmolol and nicardipine. Start esmolol first. 

Ischemic and Hemorrhagic stroke: For hemorrhagic stroke, get the systolic BP between 140-160.  For ischemic stroke patients receiving  TPA get the BP to less than 185/110.  For ischemic stroke patients not receiving  TPA, don't treat until BP is over 220.   Use nicardipine to control BP in stroke patients.  Labetalol can also be used but be very careful with labetalol. It is a non-selective beta-blocker and can cause severe asthma exacerbations in patients with asthma and cardiac collapse in patients with cardiomyopathies.

Pre-ecclampsia/Ecclampsia   Treat with magnesium and methyldopa or hydralazine.   Labetalol can be used but it can precipitate fetal distress.

Stimulant-induced (cocaine, Meth) HTN: Give benzos initially.  Benzo's usually will do the job.  if you need a second drug use nicardipine.    Avoid beta-blockers/labetalol in these situations because they can cause severe hypertension.