Conference Notes 11-8-2017

Barounis     Critical Care Tips

Tip #1   You can flush a central line with saline to verify the placement in a central vein.  Using bedside echo, if you see bubbles in right side of heart you know you are in the correct vessel. You can then start using the line right away and not wait for CXR.

Tip #2  Massive hemoptysis is life-threatening.   Patient's with large volume hemoptysis should go to the MICU. When intubating a patient with massive hemoptysis, b prepared and have 2 suction catheters ready to go.  Give TXA and if the patient is on anti-coagulation, give FEIBA.  You can try video laryngoscopy but blood likely will obscure your image of the airway so you have to be prepared to do direct laryngoscopy.  After the patient is intubated, you need to some way oxygenate the good lung and isolate the bleeding lung.  You can pass a fiber optic scope thru the ET tube and direct the tube to the non-bleeding side.  Dave also discussed a bronchial blocker device that can obstruct a bleeding bronchus. It takes some paractice to use this device reliably.

3. If you can't pass a suction catheter thru the ET tube you have to consider the patient may be biting the tube, there may be a mucous plug or clot, or the tube may have migrated to a supraglottic position.

4. 

 Lobar or lung collapse on CXR will demonstrate increased density on affected side and mediastinal shift to affected side. Treat with suctioning, nebs, chest PT and bronchoscopy.

Lobar or lung collapse on CXR will demonstrate increased density on affected side and mediastinal shift to affected side. Treat with suctioning, nebs, chest PT and bronchoscopy.

#5  Flow rate for a Cordis 333ml/min.  Other flow rates: 16g peripheral IV 220ml/min, 20g peripheral IV is 60 ml/min,   Triple lumen is 52ml/min.  Shorter, larger bore catheters deliver more volume than longer and smaller bore catheters. 

If a dialysis patient is critically ill or peri-arrest it is totally OK to infuse fluids and blood through the dialysis catheter until you can get another line.  Dave says, "It's OK."

#6 Dave gave the advice that when placing a blakemore tube for variceal bleeding introduce the tube through the nose rather than the mouth.  The balloon/tube looks too big for the nose but it will pass. Dave does not inflate the esophogeal tube in order to avoid esophogeal rupture. He says the gastric balloon usually takes care of the problem because the bleeding is usually by the GE junction.  He attaches a 1 liter bag of saline to the external portion of the tube and lets it hang over the bed rail to apply tension to the gastric balloon.

 The Blakemore tube can tamponade bleeding and allow suctioning of blood in the stomach.  Dave advised using a 1 liter bag of saline as your counter weight to apply tension to the gastric balloon.  Editor's note: I have not done this but I think I would use a clamp to attach the saline bag to the esophageal inflation port because you likely will not be inflating that balloon anyway as per Dave's advice. 

The Blakemore tube can tamponade bleeding and allow suctioning of blood in the stomach.  Dave advised using a 1 liter bag of saline as your counter weight to apply tension to the gastric balloon.  Editor's note: I have not done this but I think I would use a clamp to attach the saline bag to the esophageal inflation port because you likely will not be inflating that balloon anyway as per Dave's advice. 

#7 For neuro intubations use fentanyl and esmolol to smooth out BP and ICP elevations. Use gentle laryngoscopy to avoid ICP spikes.

Garett-Hauser      Ethics Potpourri

We had a discussion about prescribing opioids.  There were varying views among the attendees.  Everyone agreed that there has to be a balance between treating pain and avoiding opioid addiction.  The pendulum has swung to being more restrictive in opioid prescriptions based on the prevalence of opioid addiction and overdose deaths.

Euthanasia is legal in the Netherlands, Belgium, Columbia and Luxemburg.  Assisted suicide is legal in Switzerland, Germany, Japan, and Canada.  Assisted suicide is also legal in California, Washington, and Oregon Washington DC, Colorado, and Vermont.

Iceland has a policy to screen all pregnancies for Down's Syndrome. There is a 100% abortion rate for screened fetus' with this disease.  There was a discussion of the ethics of that national policy.

Next issue was the ethics of trying new un-tested therapies on patients with advanced cancer or other terminal disease. Again there was discussion weighing two sides. The first is the desire to offer patients hope and give them a last ditch treatment option. That was countered by the concern of giving false hope with untested, potentially dangerous and costly treatments.

There is a new technology being developed that uses artificial intelligence to analyze teenagers social media to screen for suicidal risk.   Cirone comment: Most teenagers have alternate Instagram profiles called "Finstas" that are more edgy than their public profiles. Their Finstas are kept secret from parents, teacher, and other adults.  Finstas are only shared among the teenagers.   We all agreed that teenagers/parents/teachers have a very difficult time dealing with social media issues.

Lovell/Williamson    Emotional Wellness

The emotionally well person is self-aware of their emotions and accepts some conflict in life as a positive thing.

Anger develops from the amygdala and is probably our most primitive emotion.  Chronic anger is maladaptive and can lead to coronary artery disease and other long term physical illnesses.

Snip20171113_1.png

One tool to limit anger/confict is ARTS of communication

A=Ask the other person about their perspective  R=Respond with empathy  T=Tell your perspective.    S=Seek joint solutions.

Logan Traylor comment: If you sense that a statement/comment you made has upset someone, it can rapidly diffuse the situation by apologizing early.

Cirone comment: Acknowledge the other person's workload and identify ways to help them. 

Ahmed comment: Identify the patient's goals and fears that they bring to their ED visit and directly address those issues.  Empowering co-workers by asking for their input is a great way to diffuse conflict.

Narrative writing can be a useful tool deal with uncomfortable emotions such as disgust. Putting thoughts on paper can better define them and make them less threatening.

Sadness needs to be processed over time. There is no quick fix for sadness.

Depression is more common in residents than in age-matched controls. The same is true for physicians in general.  Warning signs/risk factors for depression include changes in behavior, relationship issues, and substance abuse.

The vast majority of states have a Physician Health Program to provide in-depth evaluation, treatment, and monitoring to care for physicians.

As doctors, we need to develop the skill to compassionately tell families that their loved one has died.  We also need to be able to deal with the stress that we experience ourselves when a patient dies.  Post-resuscitation debriefs can be an effective tool to help caregivers process patient deaths.

Reference from Dr. Lovell:  Hyperlink to Dr. Naomi Rosenburg's excellent and brief narrative medicine essay in the NYT on how to break bad news:

https://www.nytimes.com/2016/09/04/opinion/sunday/how-to-tell-a-mother-her-child-is-dead.html?_r=0

...and the September 2017 EMRAP piece on Post-Resuscitations Debriefing:

 https://www.emrap.org/episode/mildlyacidotic/annalsof 

Fear in moderation can be a productive way to motivate us to prepare and be cautious and provide the best possible care for our patients. For our patients, we need to acknowledge their fear and do our best to mitigate their fear.

Uncertainty goes hand in hand with fear. We need to learn to manage uncertainty.  One strategy that can be effective is , "we don't have time to hurry."  Meaning we need to take the time to carefully consider the risks and plan. 

Joy is the happiness and fulfillment that we feel from our work.  If you aren't feeling joy about your work you need to consider that you may be experiencing burnout.  Ways to find joy: focus on the patient-doctor relationship. Avoid negativity. Be engaged in your workplace and value and appreciate your co-workers.